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The Lancet 2007; 370:1347-1357
Women Deliver for Development
Women as mothers: progress in maternal health over the past 20 years
Women as individuals: maternal health and women's status and empowerment
Women as family members: effects of maternal health on children and families
Women as citizens: maternal health benefits for national productivity and health service delivery
Investments in maternal health: shortfalls and potential
Summary
There is a large amount of research into maternal health as a health issue, but maternal health as a development issue has been less explored. This Review analyses the evidence from the past 20 years on the links between maternal health and development to examine maternal health within a development framework. We note that although existing evidence suggests that these links are strong, further research is needed to definitively substantiate how and to what extent maternal health and development affect each other. Further, we find that progress and investment in maternal health have lagged far behind estimates of what is needed to achieve the Millennium Development Goals.
Introduction
The reproductive years for women are of
central importance to their lives, their families and communities, and the next
generation. During these years women not only bear and raise children, but are
active members of society in many ways—as workers, leaders, and key actors in
social change and development—and have the greatest potential to deliver not
only for their own lives, but also for broader development. Since childbearing
is a key part of the lives of most women in developing countries, maternal
health probably has an important effect on their ability to fulfil this
potential. However, although much public-health research has examined maternal
health itself, there has been less focus on the assessment of evidence about
how maternal health may interact with economic and social development at family
(micro) and national (macro) levels. The Millennium Development Goals (MDGs)
have identified maternal health as a key development outcome, and thus
assessment of the importance of improving maternal health as a development goal
is essential.
Key findings
•Progress
in maternal health has been uneven, inequitable, and unsatisfactory, but
successes in several countries show that change is possible
•Women's
status and empowerment, in spheres such as education, employment,
decisionmaking, intimate partner violence, and reproductive health, affect
their maternal health including access to and use of services during pregnancy
and childbirth
•Maternal
health has profound effects on neonatal and child survival and morbidity and
grave implications for the long term wellbeing of children—particularly
girls—through its effect on their education, growth, and care
•Maternal
death and illness is costly for families because of high direct health costs,
loss of income, loss of other economic contributions, disturbed family
relationships, and social stresses
•Maternal
health affects economic productivity and overall health service delivery
•The
investment needed for improved maternal health is a minor fraction of global
spending and makes financial sense since maternal health interventions are cost
effective
We examine the evidence so far on the
links between maternal health and three of the several important aspects of
development: women's own status and empowerment; economic and social
development at the family level; and economic and social development at a
national level. Studies up until now have tended to focus on specific aspects
of development, and few, if any, have specifically examined the links between
maternal health and several outcomes of women's status and empowerment. Our
Review addresses these gaps and examines many aspects of development together
to provide a holistic analysis.
Figure 1 shows our framework. As most research up until now has shown, maternal health most directly affects a woman's own health and survival and that of her newborn child. However, maternal health is linked to women's lives not only as a health issue. A woman's maternal health is affected by, and could influence, her status and empowerment as an individual. As a member of a family, maternal health affects the health and education of a woman's children and the finances and welfare of her household, whereas in her role in a community, maternal health affects a woman's and her nation's productivity. This framework shows how maternal health is not only central to women's potential, but also has telescopic, ripple effects for broader development concerns facing the world nowadays. We assess the empirical evidence for this notion. We first examine the situation for women as mothers and review progress in maternal health in recent decades.
Figure 1. Key links of maternal
health and development
Women as mothers: progress in maternal health over the past
20 years
Status of maternal and neonatal health
Every year, more than half a million
maternal deaths occur worldwide. Further, the ratio of maternal deaths to live
births (the maternal mortality ratio) has remained unchanged over the past two
to three decades. There are large regional variations—eg, a woman in Sweden has
only a one in 29
800
risk of death related to pregnancy and childbirth in her lifetime, whereas the
risk for a woman in Sierra Leone is one in six.1
Difficulties with method and measurement make cross-country and cross-time
comparisons tenuous, except for estimates for 1990 and 2005, which have been
calculated with the same method by Hill and colleagues.2 Still, the
data overall do show some broad patterns. The first is that maternal mortality
varies greatly between regions in the world (table 1).1–4
Revised estimates for 1990 and new estimates for 2005 suggest that in those
parts of the world where maternal mortality was high in 1990 there is still a
long way to go to reach acceptable maternal mortality ratios.2 Levels in sub-Saharan Africa are
virtually unchanged between these two time periods. In south Asia, between 1990
and 2005 maternal mortality more than halved, but is still the highest maternal
mortality ratio outside of Africa. In contrast, countries in southeast and
southwest Asia have successfully reduced maternal mortality ratios to a half of
that in the early 1980s. Thus, the greatest challenge is to address the high
maternal mortality in sub-Saharan Africa and southern Asia.
;)
Table 1. Maternal mortality ratios,* 1983–2005
The scarce historical data and issues
with methods make comparisons across time very difficult for neonatal
mortality. Nonetheless, neonatal mortality remains an important concern.
Between 1980 and 2000, although child mortality after the first month of life
fell by a third, neonatal mortality rates fell only by about a quarter. Thus,
whereas in 1980, 23% of child deaths occurred in the first week of life, by
2000 this figure rose to an estimated 28%.5 Like maternal mortality, most neonatal
deaths and stillbirths happen in west Africa and south-central Asia,6 since disorders that cause these deaths
are often the same as those that result in maternal morbidity and mortality7—eg, obstetric complications8–11 and inadequate care
during pregnancy, delivery, or in the immediate postpartum period.12 As with
maternal mortality, most stillbirths and deaths to newborns and infants are
preventable.8,10–13
Maternal morbidity is also a serious problem in developing countries, but research is scarce compared with analyses of maternal mortality. Estimates are poor but suggest that 10–20 million women have physical or mental disabilities every year because of complications of birth or its management.14,15 One in four women is estimated to have acute or chronic symptoms related to pregnancy.16 4–8% of women who deliver in hospitals have severe acute maternal morbidity or severe obstetric complications (so-called near miss).17 The morbidity associated with births without a skilled attendant—which consist of almost 50% of births in developing countries—can be much higher than this finding.18 However, further research is needed to improve understanding of the nature, extent, and consequences of maternal morbidity in various regions of the developing world.
Use of maternal-health services and inequities in access
Why has maternal mortality not improved
in many developing regions? At least part of the reason is uneven and
inequitable improvement in the use of maternal-health services. Furthermore,
the low status and empowerment of women affects their access to and use of
these services.
The largest increase in the use of maternal-health services between 1990 and 2000 has been in antenatal care (table 2),19 with an average increase of more than 20% across all regions of the world.20 The increase was especially large in Asia, where service use rose by 31%. However, women in Asia continue to have the lowest levels of antenatal-care use in the developing world. By contrast, although the increase was only 4% in sub-Saharan Africa, almost three-quarters of pregnant women were using antenatal care by 2000.20 However, the high level of maternal mortality accompanying these high levels of antenatal care in Africa suggest that there are difficulties with quality of care, such as the absence of adequately trained staff, which emphasises the importance of such quality and institutional factors in lowering maternal mortality.
;)
Table 2. Antenatal care use,
1990–2000
The proportion of births attended by
skilled health care personnel also rose in all regions of the developing world
between 1990 and 2004, although this increase was uneven.21 The use of
skilled birth attendants increased by almost 80% in southeastern Asia and
northern Africa, but more than half the women in sub-Saharan Africa and
two-thirds in south Asia still deliver their children without a skilled
attendant.22 Since almost half the world's maternal
deaths occur in these two regions, the low rates of skilled attendance have
serious implications for maternal health.23
Furthermore, postpartum care has not
improved much. Most deaths to mothers and newborn children occur in the
postpartum period, with 45% of maternal deaths and 25–45% of newborn deaths
occurring within 1 day of delivery.18,24
Yet, coverage for at least one postnatal visit is on average less than 30%, and
as low as 5% in some developing countries.25
There are also strong inequalities in the distribution of services for maternal health. The poorest women in the poorest regions of the world have the lowest service coverage.21,26,27 A study in over 50 countries (figure 2)20 showed that on average more than 80% of births were attended for the richest women, compared with only 34% for the poorest women. This gap between the rich and poor is large in all regions of the world, except Europe and central Asia, and is especially wide in South Asia.20
Figure 2. Attended delivery by a
medically trained person in poorest and richest quintile (1990–2005)
Despite this severe situation, there
are success stories when poor maternal health has been substantially improved.
Egypt, Honduras (panel 1),28,29 Malaysia, Sri Lanka (panel 2),30 Thailand,
and parts of Bangladesh have all halved their maternal mortality ratios over
the past few decades.26 These
successes underscore the importance of effective health inputs to improving
maternal health31 and suggest that MDG5, which calls for
a 75% reduction in the maternal mortality ratio between 1990 and 2015, is
achievable.26,32
Panel 1:
Prioritisation of maternal health in Honduras28,29Context
The maternal mortality ratio in
Honduras in 1990 was as high as 182 per 100000
livebirths, and it was reduced to 108 per 100000
livebirths by 1997
Interventions/programmes
•Resources
were directed towards the reduction of maternal mortality, which was made a
national priority
•The
availability of emergency obstetric care services was improved, and new
services for emergency obstetric care focused on areas with high mortality
ratios
•Referrals
were improved for women who had complications both by traditional birth
assistants as well as skilled birth assistants, thus a valuable link between
the health system and clients was provided
•The
number of deliveries made with skilled attendants was increased, showing both
an increase in access and demand
Cost and cost effectiveness
Though government prioritisation and
commitment played a large part, much was made possible through the support of
various donors. Ministry of Health resources and foreign aid were redistributed
towards resolving the problem. The country spends about 7·2% of its gross
domestic product on health and social services
Effect
Despite being one of the poorest
countries in the western hemisphere, Honduras challenged the problem of
maternal mortality and has reduced maternal mortality by 38% over 7 years
Panel 2:
Reduction of maternal mortality in Sri Lanka30Context
The maternal mortality ratio in Sri
Lanka in the 1940s was over 1600 per 100000
livebirths. As of 2000, this number has been reduced to 92 per 100000
livebirths
Interventions/programmes
Key actions contributing to the
country's success included strong public investments in the overall health
system, while taking special care to include crucial elements of maternal
health care. Fundamental to their progress was sustained commitment for
maternal-health care priorities with financial, managerial, and political
support. Additionally, special attention was given to specific, sustained strategies
in health, education, and nutrition, including equitable access to these
services early in the development stage. Specific steps taken by the country
for maternal health care included:
•Ensuring
access through the expansion and provision of a free synergistic package of
basic comprehensive health and social services, including maternal health care
that reached poor people, even in rural areas
•Use
of a judicious mix of health personnel to deliver services. Midwives were
certified and provided an integral link between the women and the health units
•Effective
management and use of health information to serve as a foundation, guiding
decisionmaking and identifying problems
•Use
of information for quality improvements, especially in identified vulnerable
groups
•Empowering
clients to provide information and to use services effectively
Cost and cost-effectiveness
In the late 1950s, Sri Lanka's gross
national product per head was US$270 (1995 US equivalent), and about half the
households were below the poverty line. The country was able to reduce maternal
mortality despite a decreasing budget. Between 1950 and 1999, expenditures for
maternal-health services decreased from an average of 0·28% of gross domestic
product in the 1950s to 0·16% in the 1990s, with an average of 0·23% over the
five decades from 1950–99
Effect
The country has shown the capacity to
reduce maternal mortality ratio by 50% every 6–12 years
Poor maternal health is of serious
concern beyond its importance as a health issue, because women's health as
mothers can be linked with other aspects of women's lives and development more
broadly. We assess what evidence exists to support these links.
Women as individuals: maternal
health and women's status and empowerment
Research suggests that the MDGs will not be reached without addressing poverty and gender inequality.33 As WHO noted, “Maternal mortality is an indicator of disparity and inequity between men and women and its extent a sign of women's place in society and their access to social, health, and nutrition services and to economic opportunities”.12 The evidence reviewed below shows that women's status and empowerment—measured by education, employment, intimate partner violence, and reproductive health—affects women's capacity to access and use services during pregnancy and childbirth or otherwise maintain good maternal health. In some cases, the evidence also suggests that maternal health affects women's status and empowerment as well.
Enablers for improved women's status: education and employment
Education and employment are termed
enabling factors since they can be instrumental in enabling women to gain the
knowledge, confidence, skills, and opportunities that they need to increase
their social and economic status and power in the household and in society.
Some studies have examined the links of both these enablers with maternal
health.
Perhaps the clearest and best
documented example of the link between women's status and maternal health is
the effect of women's education on maternal health. Educational attainment is
measured by years of schooling, levels of education, and leaving school before
secondary school completion. Extensive reports show that women's education
increases the use of maternal-health services, and is independent of related factors
such as urban or rural residence or socioeconomic status, and across the range
of services and stages of maternal care.34–40 Educated women are
more likely than are uneducated women to use antenatal care, to use it early
and frequently, and to use trained providers and medical institutions.34–40
Similarly, education is positively associated with safe delivery35,36,38–40
and an increased use of postnatal care.37 Education results in substantial
improvements in a woman's own health as a mother, and also has positive
intergenerational effects on the health and nutrition of her daughters and
their households.41 Female education, along with trained
delivery assistance, is also a strong predictor of maternal mortality, independent
of income per head.42
Women's economic opportunity (measured
in terms of involvement in gainful or paid employment, wages, type of occupation,
status at work, sector of activity, work effort, and potential wage rate) also
has the potential to affect maternal health. Employment can pose physical
burdens, hazards, or stress on women, which could result in negative outcomes
for maternal health. Conversely, experiences and roles as economic providers
might empower women through increased control over income which, in turn, may
increase their power in decisionmaking about health care and their ability to
access and pay for the services that they need when they are pregnant. The
evidence suggests that women's employment positively affects maternal health,
although the research is scarce compared with that for the link between
maternal health and education.
Existing research shows that employment
is associated with reduced maternal mortality and morbidity and increased use
of maternal-health services, even after considering other factors such as
education, age, household assets, and neighbourhood characteristics.43–46 Studies in several
countries have shown that unemployed women had over four times the chance of
maternal death compared with employed women,46 and a
substantially higher likelihood of episodes of illness in the 2 years after
childbirth.44 Employment and participation in credit
programmes were positively correlated with seeking antenatal and postnatal care
services in China and the Philippines, respectively, and with women demanding
formal health care in the event of an illness in Bangladesh.43,45,47
These studies suggest that women's participation in economic activities and control of own income is more important to improvement of maternal health than is household socioeconomic status per se, perhaps because economic control increases women's ability to access the resources that they need during pregnancy. Other research emphasises how economic disadvantage more generally affects maternal health negatively, through factors such as residence in a poor neighbourhood and absence of toilet facilities and potable water.46,48 Since women's economic contributions raise the standard of living of their households, they might contribute to improved maternal health through this additional route as well.
Women's empowerment: household decisionmaking and intimate
partner violence
Several studies suggest that although
education and employment might be enabling factors, decisionmaking in the
household and experience of intimate partner violence are more direct measures
of women's ability to make crucial life choices.48 These factors indicate the power
dynamics women face in terms of other family members in their efforts to secure
their own welfare and frequently, that of their children. They also show
women's value in the household and the effort and resources that will probably
be spent in ensuring their wellbeing. Although research into these links is
scarcer than it is for education and employment, it does show some consistent
findings.
Almost all the studies that connected
decisionmaking with maternal health reported that, independent of other
factors, women's involvement in decisionmaking on key aspects of life is
associated with an increased use of maternal-health services.38,49–53
Moreover, the stronger the woman's decisionmaking power, the greater the effect
on maternal health. Women with strong decisionmaking power were more than twice
as likely to deliver their child at a health facility compared with women with
little decisionmaking power.51 Similarly, women from households with a
female head and those who alone had the final say on decisions were
substantially more likely to use health services and deliver at a health
facility than were other women.49–51 Finally, the
association between women's decisionmaking and health service use was two to
three times larger when both the husband and wife agreed that the wife had
power in decisionmaking.49
Evidence for intimate partner violence
from around the world shows that violence during pregnancy can be common.54 However, the relation of violence with
pregnancy varies by location. Some studies report that pregnant women are more
likely to experience violence than are women who are not pregnant.55,56 Surveys from several
countries show that intimate partner violence during pregnancy in developing
countries ranges from 1·3% of pregnant women in Cambodia57 to 27·6%
in a province in Peru.58 However, these studies also suggest
that there is no consistent pattern of change in violence during pregnancy;
although in some countries the level of violence during pregnancy is higher
than it is when a woman is not pregnant, in other areas the reverse may be
true.
Although the extent of violence during pregnancy varies, studies consistently show that violence is associated with many negative outcomes for maternal and fetal health, including premature and low birthweight babies, low maternal weight gain, infections, anaemia, smoking, alcohol and drug use, and depressive symptoms.55,59–61 Analyses across several developing countries show that women who experienced violence were substantially more likely to have a terminated pregnancy or non-livebirth than were women who did not experience violence.57,62 They are also likely to have poorer maternal health because they are less likely to access antenatal, delivery, and postnatal care.57,58 They are twice as likely as other women to delay antenatal care until the third trimester,55 and have a 37% increased risk of obstetric complications requiring admission to hospital before delivery.61 Violence can also indirectly contribute to women's isolation during pregnancy through its control over their lives and access to resources.61,63
Reproductive health: contraception, abortion, and HIV/AIDS
Options and constraints that women face
regarding other reproductive health issues such as contraception, abortion, and
risks of HIV can affect their health as mothers. Because of gender-based power
dynamics with regard to sexuality in many cultures, women often do not have the
power to negotiate safe sex or to prevent or safely abort unwanted pregnancy.
As a result, women can be vulnerable to increased risks of maternal morbidity
and mortality, especially in the context of HIV, because of risky sexual
experiences as well as pregnancies that arise under difficult circumstances.
Extensive research shows that
contraceptive use contributes to improved maternal health and lower maternal
mortality, by contributing to fewer births, fewer unwanted pregnancies, and a
lower proportion of births that are high risk.64–66
There is little research into the effect of maternal health on contraception,
but a few studies show that women who use maternal-health services are more
likely to use contraception than are women who do not use maternal care.67,68
The negative effect of unsafe abortion
on maternal health is also well documented. Unsafe abortions increase both
maternal mortality and morbidity—eg, through haemorrhage and infection, severe
pain, secondary infertility, and death.69 WHO estimates that about 68000
maternal deaths—mostly in developing countries—are due to abortion every year,
which is probably a large underestimate because of widespread problems with
reported abortion rates.70 Maternal
deaths related to abortion are highest in Latin America and the Caribbean,
where abortion is largely illegal. Unsafe abortion is one of the major direct
causes of maternal mortality and morbidity in developing countries, and it
accounts for 13% of maternal deaths.70
Conversely, safe or legal abortion poses little risk; in developing countries,
the mortality risk is only four to six per 100000
cases for legal abortion compared with 100–1000 per 100000
cases for illegal abortions.70 Thus women's options for safe abortion
services are an important determinant of maternal-health outcomes.
HIV is becoming an increasingly
important cause of maternal morbidity and mortality. Women are especially at
risk of HIV; over 17 million women are infected with HIV, and every year two
million pregnancies occur in women who are HIV positive.71,72
AIDS is now the leading cause of maternal deaths in some areas of Africa.72 HIV directly increases the risk of
complications of pregnancy, delivery, and induced abortion such as anaemia,
haemorrhage, and sepsis, thereby causing a high number of maternal deaths and
complications.73–75 HIV indirectly
increases susceptibility to episodes of moderate to severe maternal morbidity75 and the chance of a maternal death due
to opportunistic infections such as pneumonia, tuberculosis, and malaria.73,76–80
Maternal health is also thought to
affect HIV because pregnancy can accelerate disease progression in women who
are HIV positive, although the supporting evidence has produced varying conclusions.
Research results from developed countries show no effect of pregnancy on HIV
disease progression, immunodeficiency, or AIDS.81–83
However, evidence from developing countries, where HIV is accompanied by a
greater degree of symptomatology than it is in developed countries, suggests
that there could be a link.73,84–87
Thus there is strong evidence that indicators of women's status and empowerment such as education, decisionmaking, contraception, unsafe abortion, intimate partner violence, and HIV status affect outcomes for maternal health. However, research is scarce for the effect of employment on maternal health. Evidence on the reverse links—ie, the effect of maternal health on women's status and empowerment—is even scarcer. Yet poor maternal health could plausibly affect women's ability to exercise power or improve other dimensions of their lives such as employment opportunities. Further research is needed to verify these links, and to investigate how maternal health affects overall development through its effect on factors related to women's status and empowerment.
Women as family members: effects of maternal health on
children and families
That maternal health and mortality are
of fundamental importance to the survival and wellbeing of children is
well-documented. However, the evidence of the costs of maternal death and
illness on families is scarce.
Many studies have shown that a child's
risk of dying increases substantially after the mother's death.88–93 Moreover, maternal
death seems to be one mechanism for perpetuating gender inequality in the next
generation; the child's risk of death when the mother dies is higher for girls
than for boys.88,89
Children whose mothers die are also more likely to be stunted94 and less likely to attend school.92–94
When a mother dies or is severely ill, children are more likely to be sent to
foster care, where they might have an increased chance of death, disability,
and poor nutrition and of receiving less education and health care.95 Studies on orphanhood are exploring
these negative effects, as well as potential benefits, of foster care.96–99
Poor maternal health perpetuates the
cycle of ill-health across generations. Women who do not gain enough weight
during pregnancy increase the chance that their newborn children are of low
birthweight. Girls who are born underweight are more likely to be stunted,
underweight adults and to have obstructed labour, which endangers their lives
and that of their newborn child.100 Birth asphyxia can cause brain damage
and impede cognitive development, and poor health at birth can affect adult
wellbeing—eg, through increased chance of death from cardiovascular and
cerebrovascular diseases.4
An increasing amount of evidence draws
attention to the costs of a maternal death or illness to a household.10,101–104
These costs can drain family resources and savings, change patterns of
consumption, and reduce households to debt and poverty.102,105 For instance, in
Indonesia, a hospital delivery with complications cost 14% of an average yearly
income.102 In Ghana
and Benin, families could spend US$115 or $256, respectively, to treat near-miss
complications. In 2000, these costs represented 8% of average annual cash
expenditures for Ghanaian families and 34% in Benin.106 When women are important economic
contributors within their families, maternal illness means fewer hours of paid
work, less income, and reduced resources for a family, exacerbating economic
insecurity. Research in Ghana shows that women lost an average of 26 days of
work because of reduced productivity during pregnancy and 23 days during
postpartum.102 A review of US studies linked the poor
health of mothers with reduced wages and labour-market participation, and
increased welfare dependency.107 Poor maternal health also restricts
women's important non-paid economic contributions such as food production,
water collection, health care, and caring for children, those who are ill, and
elderly people.103,104,108
The psychological and social
consequences of poor maternal health and mortality are less extensively
documented than are the economic costs, but existing published work suggests
these factors are important. Rahman and co-workers' study showed that one in
four women in Pakistan had antenatal or postpartum depression,109 which is
a disorder that has been linked to disturbed relationships with children,
marital discord, and poor performance of household tasks,109–111
but which can be ameliorated with good health care.101 In many
societies, men are not raised, taught, or expected to manage household affairs and
they are poorly equipped to care for children and families. When maternal
illness or death occurs, there is evidence of increased depression and
psychological problems in the family, and increased numbers of children leaving
school because they are compelled to help earn income.112
Despite these negative results of maternal morbidity and mortality, women's low status in a household typically means that women's health-care needs are ignored and given low priority. Further, childbearing is regarded as an expected part of a woman's role. Thus, families are reluctant to invest in maternal care and women may be unable to negotiate better care; thus, the risks and costs of maternal morbidity and mortality persist.113
Women as citizens: maternal health benefits for national
productivity and health service delivery
In view of the costs and negative
consequences associated with poor maternal health for women and their families,
the cumulative effect of maternal mortality and morbidity probably affects
national and global development outcomes. Of all the three aspects of
development that we have presented in this Review, research is most scarce for
the relation between maternal health and national development. However,
existing published work does point to a negative effect of poor maternal health
on development.
Cost estimates in recent years have
tried to quantify the effects of maternal deaths and illnesses on national
budgets and productivity, on the basis of various assumptions. The US Agency
for International Development (USAID) estimated global maternal mortality costs
of over US$15 billion every year because of diminished potential productivity
caused by the death of women and neonates.114 Estimates for four countries suggest
that costs of total productivity losses per year associated with poor maternal,
newborn, and infant health range from US$8 million in Mauritania to $95 million
in Ethiopia, on the basis of figures for 2001.115 Annual productivity losses per head
range from $1·5 in Ethiopia to over $3 in Uganda and Mauritania, and almost $5
in Senegal.112 With
somewhat different assumptions, and household and health centre costs added to
such estimates, the annual cost for lost productivity in Uganda is closer to
$102 million per year or $4·25 per head per year.112
Further evidence shows that maternal
morbidity and mortality represent an important burden of disease in the
developing world. In women of reproductive age, maternal ill health is one of
the leading single causes of death and disability, accounting for 13% of deaths
and 13% of DALY's (disability-adjusted life years).116–118 Furthermore,
maternal health and the quality of obstetric and newborn care are directly
associated with perinatal disorders (birth asphyxia, trauma, and low birthweight),
which are the second leading cause of premature death and disability in
children younger than 5 years and which account for about 20% of the burden of
disease in that age group.16
Although research has not explicitly
explored the effect of poor maternal health on economic growth, evidence
suggests a positive relation between health overall and economic growth.119–121
Since estimates for the burden of disease show that maternal mortality and
morbidity is one of the largest single causes of ill-health for women, it can
reasonably be assumed to account for an important portion of the effect of
overall adult health on economic growth. Studies for the economic effect of
AIDS support such an assumption. Since individuals are affected in the prime of
their productive lives, AIDS substantially alters economic growth,
productivity, investment, domestic savings, poverty, and inequity.122–124
Like AIDS, maternal morbidity and mortality also affects women at the prime of
their lives when they have the greatest ability to contribute to society and
the economy, and it has severe economic repercussions for families and
represents a large burden of disease. National economic outcomes are similarly
affected. However, further research is needed specifically on the consequences
of maternal death and disability to provide the empirical evidence to support
these theoretical links.
Evidence suggests that investment of resources in maternal health can at least partly address these issues through its positive effect on overall health service delivery and use. Maternal health indicators are so closely associated with key service delivery issues such as equity and efficiency that they have been used to assess the functioning of health systems125 and proposed as a measure of the performance of a country's overall health system.16 Investments in key maternal-health facilities—eg, essential obstetric care—can be used for other types of services such as operations and blood transfusions for accidents.126 Prevention of maternal morbidity avoids the large costs of treating maternal-health problems.101 Finally, research shows that women who use maternal-health services are more likely to use other reproductive-health services than are those who do not use such services, thus creating a multiplier benefit for several reproductive-health outcomes.68
Investments in maternal health: shortfalls and potential
Investments in maternal health continue
to fall below what the development community knows is necessary to achieve the
benefits of maternal health and the MDG goal for safer maternity. Although
there are many other important barriers to improving maternal health—such as access,
quality of care, and cost—adequate investment in maternal health is an
essential first step to addressing them all.
There are several estimates of what it
would cost countries to try and reach MDG5, ranging from as low as US$1 billion
in 2006 to as high as $6 billion in 2015. Cost estimates per head range from
$0·22 to $1·40.127–129
Estimates of costs and investments make different assumptions and are not
strictly comparable, but available evidence shows a wide gap between present
investments and what is needed to meet MDG5.125,130–132 International
development assistance for maternal and neonatal health was estimated to be
$664 million in 2003 and $530 million in 2004.130 Analyses of the outlook for future
overseas development funding are mixed,125,130
but they suggest that donor funding will need to increase over 11 times its
2004 level to achieve the $6·1 billion that WHO estimates is needed for 2015.
The good news is that the gap between
present and needed investment for maternal health represents only a small
fraction of donor gross national product and of total development aid. Even the
much larger $5 billion shortfall in estimated funds that is needed by 2015 to
meet both maternal health and child health MDGs consists of only 0·016% of
global gross national product and 2% of aid.133 The investment that is needed to
improve maternal health is a small fraction of world spending, and it makes
financial sense because maternal health interventions are cost effective.33,104,116,125,126,134 A
World Bank study116 noted that antenatal and delivery care
and family planning were two of the six most cost-effective interventions
selected for the essential package of clinical services for low-income and
middle-income countries. A recent study33 showed that primary care interventions
for mothers and neonates, and preventive community-level interventions for
newborn children, were highly cost effective for settings in sub-Saharan Africa
and southeast Asia where the rates of adult and child mortality are high.
Hospital-based interventions were also reported to be cost effective and
essential to efforts to substantially reduce maternal and newborn mortality.
Conclusions
The continued scarcity of progress in maternal health
over the past two or more decades in several parts of the world is disturbing.
The little progress is especially of concern for south Asia and sub-Saharan
Africa, which have consistently presented the worst maternal health in the
world. Our Review suggests that the fact that these regions also lag in
progress on a range of broader development outcomes, including poverty
reduction and the status of women, is no coincidence; even the little research
so far points to the likelihood of a strong link between maternal health and
other women's status and development outcomes. Similarly, that many countries
in southeast Asia have made great progress is also no coincidence; in many of
these countries, investments in improving the availability and quality of
maternal care services have gone hand-in-hand with investments in education and
employment for women, and in the provision of a range of reproductive health
services. Thus, the examples of countries like Thailand26 and Malaysia30 suggest that MDG5 is achievable with
appropriate financial and political commitment.
Our Review emphasises some key limitations in the published work. Most notably, additional research is needed on how poor maternal health affects women's status; the many ways in which it affects women's productivity, household wellbeing, and national economic growth; and on how women's status and broader development, in turn, change the patterns and extent of improvements in maternal health. However, additional evidence alone will not be enough to ensure future progress. Concerted efforts also are needed to change public perceptions about the severity of the problem and the solutions that are available, and to create a coalition of stakeholders committed to improving maternal health.135 The convergence of such actions, along with a growing understanding of the links between maternal health, women's status and broader development, and adequate investment in maternal health and in women will enable women to fulfil their potential to deliver as mothers, individuals, members of families, and citizens.
Search strategy and selection criteria
All searches were done with literature
databases such as POPLINE, PubMed, Proquest, Social Science Citation Index, and
the websites of international organisations and universities such as WHO, the
World Bank, UNICEF, the UN, UNFPA, the US Agency for International Development,
Population Reference Bureau, the Global Health Council, the London School of
Economics, the London School of Hygiene and Tropical Medicine, Oxfam
International, and the Immpact Initiative. Searches were limited to published
work produced in the past 10 years, with the exception of key articles in the
discipline. Searches on maternal health included the following key terms:
“maternal mortality”, “maternal morbidity”, “obstetric morbidity”, and
“maternal health services utilization” (antenatal, delivery, and postnatal
care). Key terms used for investments in maternal health included:
“investments”, “(donor) funding”, and “millennium development goals”. For the
relations of economic opportunities to maternal health, we added: “employment”,
“wages”, “enterprise”, “savings”, “assets”, “economic opportunity”,
“occupation”, and “microcredit”. Searches for links of maternal health with
development outcomes used search terms such as: “disability-adjusted life years
(DALYs)”, “burden of disease”, “cost-effectiveness”, “child education”,
“household finances”, “family”, “individual effects”, “household-level
effects”, and “adult mortality consequences”.
Conflict of interest
statement
We declare that we have no conflict of
interest.
Acknowledgments
We thank Michelle Lee, our research
assistant, who identified, reviewed, and managed all the literature for us, as
well as giving very useful input into the paper; and Ann Starrs at Family Care
International for comments on previous versions of this paper. Work for this
Review was supported by Family Care International through a grant to the
International Center for Research on Women. The funding source had a role in
the review of content for this article, but has no responsibility for the
information provided or views expressed in this paper.
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