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Published in the Huffington Post September 23, 2009

By Ann Pettifor and Maz Kessler, Advocacy International

President Clinton was on Larry King the other night, reminding us with typical directness that people die simply because they can’t get medicine. This is particularly true for poor women and their newborn babies.

Women - mothers - are still dying in pregnancy and childbirth, all over the world, for want of cheap, standard medicines that we take for granted.

But today a new article is published in The Lancet that could transform the attitudes of donors and decision makers and potentially save millions of women’s lives.

Dr. Christina Pagel and Professor Anthony Costello of UCL model three different interventions for reducing the number of mothers’ deaths. One of these interventions - delivering medicines to mums both in clinics and in the home - could potentially reduce mortality by as much as one third. One third! It’s important to understand how significant this number is in light of the last 20 years. Over these 2 decades the number of women dying in childbirth has scarcely budged, and in some regions has gotten worse.

A result coming anywhere close to such a reduction would be a stunning breakthrough.

Richard Horton, the editor of the Lancet rightly notes that Dr. Pagel and Professor Costello’s proposal/model “has the potential to transform our attitudes to maternal health. We might now contemplate donor-funded drug-delivery programmes akin to those for HIV-AIDS and TB - in addition to health-facility strengthening.”

Of course it’s clear that the safest births take place in well-stocked facilities with trained health workers to care for mothers and their newborns. There are antibiotics for infection. Medicine to stop post-partum hemorrhage, and equipment for emergency care - including the ability to perform C-sections. Providing this for all mothers must be our long-term goal.

But in the meantime, something must be done - urgently.

Because whether we like it or not, over the next 10 years 400 million of the world’s poorest women will deliver their babies at home, often on mud floors, in modest huts. 10 million of these women will die unnecessarily, many from infection and hemorrhage - both of which are easily treated with affordable, standard medicines. As a result of their deaths children will die, families will suffer and go hungry, and communities will be impoverished.

How can these deaths be prevented?

The answer is straightforward - as Clinton suggests - increased access to cheap standard medicines. To this we would emphatically add training for an army of women health workers able to care for mothers and newborns in their homes and villages. As a bonus, this training will lay the foundations for a strengthened health system.

When we first looked at this challenge two years ago, Professor Costello reminded us of our own history both in the UK and the US: that women stopped dying in childbirth in large numbers only when antibiotics came widely into use.

However when discussing women in poor countries we tend to forget this history. Instead we have convinced ourselves that in Africa and Asia the issues are too complicated to begin to address with straightforward Clinton-style approaches — or too complicated to invite the public to back a massive campaign (like AIDs campaigns for ARVs, or distributing bed nets for Malaria).

They’re not.

The public - particularly the immensely powerful constituency of women and mothers worldwide - would jump at the chance to be involved in such a campaign. But only if there is an effective, affordable solution to rally around, such as the bed net, antiretrovirals or vaccinations. Fortunately, thanks to Pagel and Costello we now have the findings to justify investing in such a solution and campaign.

It’s time to stop agonizing. It’s time to stop believing that this issue is too complicated to be solved.

It’s time to give mothers a break.

Viva Mama!

This brilliant work goes straight to the heart of the discussion about “in the meantime” solutions for saving mother’s lives that has been reverberating through the maternal health community all year. We’ve been advocating for drug distribution and treatment at the community level by community health workers and women volunteers as an immediate solution… acknowledging that more than 50% of mothers in the developing world still deliver at home, and facility delivery for all these mothers just cannot realistically be achieved any time soon. (See our previous post “A complimentary approach to saving mother’s lives?”) It’s incredibly exciting to see statistical models that demonstrate how community delivery of medicines could increase maternal survival significantly - particularly in the poorest quintile! A pro-poor solution indeed.

The study compares the impact on maternal survival of 3 approaches - Health facility strengthening alone, Health facility strengthening PLUS antenatal care and community health workers, and both of the above PLUS women volunteers in villages able to provide access to drugs and treatment.

Here’s an excerpt from the study:

“Provision of life-saving drugs to prevent or treat hemorrhage and sepsis might be possible through antenatal clinics, community health workers, or even women community volunteers at the village level, in the same way that child survival has improved through community distribution of anti-malarials and antibiotics.”

Absolutely! And of course - the medicines under consideration are antibiotics and misoprostol… I’ll post a pdf of the study as soon as it’s available.

I’ve been working on Debtonation with Ann Pettifor for several months. For those who don’t know her work, Ann is one of the very few economists who accurately predicted the current global financial meltdown. As early as 2003 she warned of an Anglo-American debt-deflationary crisis - not exactly a popular position at the time, and she continues to call it right. So check out Debtonation for independent and forthright analysis of the incredible mess we’re in. Here’s an excerpt:

“It is hard to over-state the gravity and extent of the collapse of the global economy. I can barely find the words to fill a blog that I fear you, dear reader, may weary of.  It is even harder to find an economy escaping the carnage, or to avoid politicians dashing for the cover of bail-outs.  But one can still encounter economists confident and chipper in the face of such massive, global destruction – and the threat of sustained economic failure.”

Maternal survival advocacy has so far taken place on the “inside” professional advocacy track, without the crucial “ballast” of public awareness and support. There has not yet been an effective public advocacy campaign that gives voice to mothers, delivering the facts and offering positive and effective solutions to the global public. As a result there exists virtually zero public awareness and engagement around the neglected tragedy of maternal deaths.

Funding for MDG 5 is the lowest of all of the MDGs, and maternal survival has not achieved the necessary political priority to generate adequate resources and commitment. Vibrant and uncompromising public mobilizations have powered other public health movements, and innovative design and fresh funding models via the web have brought a whole new generation of public engagement and resources to issues such as micro-financing, global poverty and malaria.

It is time to bring the stories of mothers to the public. We believe that a global, women-led public campaign is the missing piece of the maternal advocacy landscape.

More than 50% of mothers in low-income countries still give birth in the home, far from health facilities, medicines and trained professionals .

Why? These women often live in remote and inaccessible rural areas. And even if health facilities and trained professionals are within reach, many women confront insurmountable cultural and religious obstacles in accessing that healthcare and inevitably give birth at home.  Plus, their governments face significant economic challenges, made worse by the exodus of trained medical staff to rich countries.

Given these and other constraints, there is scant hope that enough clinics will be built, medicines provided and skilled medical staff recruited in a 5 to 10 year time-frame to eliminate life-threatening risks faced each day by women in pregnancy and childbirth. It will take many years before 100% of all births in low-income countries take place within facilities attended by skilled professionals. In the meantime one woman will die every minute in childbirth, while millions of others will suffer physical or mental harm.

Maternal health advocacy has been focused on the long-term goals of building and resourcing facilities, as part of strengthening health systems, with some advocates decrying any interim, or ‘in the meantime’ solutions, such as supporting community-based delivery of care.  The implication has been that saving lives now, through such solutions, might weaken the political will of governments to embark on the long-term and expensive task of strengthening health systems.

We strongly disagree with that position. There may be an opportunity, by complimenting and augmenting a health systems strategy, to prevent and treat maternal illness in the community. Mothers’ deaths and injuries could be prevented in the home by community or village health workers trained and equipped with life-saving medicines.

NGOs have for many years provided “clean birth kits” to village level health workers consisting of items such as soap, gloves and clean razorblades, but these do not include essential life-saving medicines, and cannot be effective in treating life-threatening conditions, including postpartum hemorrhage and infection.  Training for TBAs (Traditional Birth Attendants) has been largely abandoned after maternal survival rates did not significantly improve as a result of these training programmes in the late 1980s and early 1990s, but the TBAs were not equipped with life-saving medicines that can prevent maternal death. There is now a re-evaluation of community-based care underway, driven in large part by physicians and health workers from low-income countries with a “reality-based” approach to saving mothers’ lives in the immediate term.  Practical solutions are once again under consideration and development, driven by the emergence of safe, effective and easy-to administer medicines such as misoprostol for postpartum hemorrhage, and compelling data on the community-based delivery of antibiotics.

Life-saving, tried-and-tested medicines administered by community and village-level health workers will help to address the immediate emergency of maternal mortality. Such an approach will also provide a tangible and specific “ask” that the global public can rally and fundraise around, just as in campaigns for vaccination, bed nets and anti-retroviral treatment. Furthermore such a campaign will have the added benefit of raising awareness, building demand from women and generating political will for comprehensive health systems to save mothers’ lives.

The second report comes out of a partnership of the UN Foundation and Vodafone. The report is called Wireless Technology for Social Change: Trends in Mobile Use by NGOs and examines real-life examples of and trends in wireless technology solutions being used to drive change in the areas of health, humanitarian assistance, and environmental conservation. (and there’s a very real-life fish head on the title page photo montage)

In some of the world’s poorest countries, women still die in pregnancy and childbirth at what is essentially the same rate as the Middle Ages. Nature seems to have given odds of around 16 to 1 of successfully making it through pregnancy and childbirth without any medical help or modern advances in hygiene. Unbelievably, women in the poorest countries still face this same risk TODAY when entering each pregnancy. What continues to kill these mothers now are exactly the same causes that made childbirth such a dangerous enterprise until the 20^th century – infection, hemorrhage, lack of emergency obstetric care (c-sections), unsafe abortion and eclampsia. The causes are well known (although the percentages remain controversial).

And there’s an additional twist to these figures. When a woman is also denied her rights, her risk more than doubles. In countries where women have no status, out of every 7 woman and girls that become pregnant, 1 will die.

Pregnancy remains the leading killer of women in their reproductive years in developing countries.  According to WHO, the number of women dying from pregnancy and childbirth shows the highest difference between the poor and the rich of any health metric.

A team is coming together to create a new public mobilization campaign for maternal survival. The goals of the campaign are to mobilize women worldwide and provide a clear and credible “ask” supporting life-saving interventions that can be implemented now. We’re incredibly excited to get this effort rolling, and have just begun the first stages of planning.

There are of course important organizations and advocacy efforts for maternal and newborn health in existence, but none of them have so far managed to translate the complex facts of maternal survival into clear, motivating messages  for a global public audience.  In addition there must be a clear and effective “ask” for the public, once mobilized, to rally and fundraise around.

We’re going to post some of the basic ideas for the campaign here.