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  • Anna Lucas
    Anna Lucas , Coordinator of the Maternal, Child and Reproductive Health Initiative
  • Preventable Deaths in 2016. The Access of the Poorest Women to Maternal Health Services


    [This article is written by Anna Lucas and Clara Menéndez, coordinator and director, respectively, of the Maternal, Child and Reproductive Health Initiative at ISGlobal and it has been published in Spanish in El País - Planeta Futuro]

    The prevailing narrative in maternal global health today is one of optimism. Advances are more visible than ever before. The message we see in most forums is that the (good) health of women and children is an indispensable prerequisite for the prosperity of countries and communities, for political stability and for greater equity.

    Lack of access to maternal healthcare services causes over 5 million stillbirths among the poorest women in the world

    Even so, in 2015—the target year for the Millennium Development Goals (MDGs)—over 300 000 women died in childbirth or in the hours and days following delivery, and this figure rises to over 5 million deaths when we include stillbirths in the final stages of pregnancy or at birth and neonatal deaths during the first month of life. And these, for the most part preventable, deaths were the direct result of a lack of access to quality health services during pregnancy, childbirth and the postpartum period.

    In the developing regions of the world, obstetric complications (haemorrhage, infection, high blood pressure, obstructed labour) and most of the indirect causes of maternal mortality and morbidity (malaria, syphilis, HIV, anaemia, cardiovascular diseases) could be prevented or treated if proper medical care were available. What is more, the lack of access to maternal and reproductive healthcare services means that pregnant women pay an even higher price than the general population in emergency situations, as was highlighted by the recent Ebola and Zika virus epidemics.

    Looking back at the last fifteen years, it is in these areas—particularly the coverage of skilled birth attendance—that most countries spectacularly fail to meet the standards required by the MDGs. In low- and middle-income countries, only about half the women of reproductive age have access to contraception, attend at least the four recommended antenatal visits during pregnancy, or have the benefit of skilled attendance during childbirth.

    Pregnant women pay an even higher price than the general population in emergency situations

    Once a country has a health system that provides universal prenatal care and skilled birth attendance, improvements in maternal and neonatal mortality indicators are seen within a few years. The results can be seen in our own country, where maternal deaths are a rare occurrence. Without underestimating the other factors, within or outside of the health system, that prevent  women from receiving the care they need before, during and after childbirth (the physical distance they must travel to access health services, the perceived quality of the services, the woman’s educational level or degree of personal autonomy), financial barriers continue to be the main obstacle.

    For how much longer can we avoid addressing the central issue in improving maternal and child care? How long can we continue to allow peripheral issues (such as the use of new technologies for improving maternal health) to distract us, to occupy too much space on the agenda, and to consume resources.

    On the other hand, the evidence now emerging about the impact of the policies and programmes implemented during the last two decades shows that the (slow) advances in general terms have not improved access to maternal health services for the poorest women on the planet. The improvement observed in the indicators has been driven predominantly—often exclusively—by changes affecting the situation of women with a higher income level, who often benefit from the widening gap that separates them from those in the lowest income bracket. It is also urgent, therefore, to ensure that policies prioritise the most  disadvantaged women.

    Maternal health will improve when we have health systems that can provide basic quality care for all women

    Is there any prospect of that happening? There are some encouraging signs. Despite the financial challenges, more than one hundred low- and middle-income countries are moving towards healthcare systems that seek to provide Universal Health Coverage (UHC). In other words,  they are moving towards a situation in which the whole population has equal access to essential healthcare services and no one will face serious financial difficulties or be reduced to poverty to pay for healthcare. And if, because of limited resources, the strategy chosen is to prioritise the most cost-effective services, prenatal care and attended childbirth should be considered fundamental in any proposal and the general focus should be on UHC and prioritising the poorest sectors of society, in a reversal of the trend seen in recent decades.

    In a different type of initiative, a new instrument has recently been launched that implicitly recognises the historical deficit in terms of financing and global political will. The aim of the Global Financing Facility, which recovers the idea of a global fund for maternal and child health, is to combine the efforts of all the actors involved (the countries where most maternal and neonatal deaths occur, which should play a leading role in  this initiative, multilateral and bilateral donors, civil society, the private sector as well as UN and World Bank agencies).

    In this first year of the new era in global development—the era of the Sustainable Development Goals (SDG)—we do not need to launch a new message:  what is needed is to remind ourselves that maternal health will improve when we have health systems that can provide basic quality care for all women, irrespective of their income or educational level, or where they live. That would be a novelty.