a report of the csis global health policy center Improving Maternal Mortality and Other Aspects of Women’s Health the united states’ global role 1800 K Street, NW | Washington, DC 20006 Author Tel: (202) 887-0200 | Fax: (202) 775-3199 Phillip Nieburg E-mail: [email protected] | Web: www.csis.org October 2012 CHARTING our future Blank a report of the csis global health policy center Improving Maternal Mortality and Other Aspects of Women’s Health the united states’ global role Author Phillip Nieburg October 2012 About CSIS—50th Anniversary Year For 50 years, the Center for Strategic and International Studies (CSIS) has developed practical solutions to the world’s greatest challenges. As we celebrate this milestone, CSIS scholars continue to provide strategic insights and bipartisan policy solutions to help decisionmakers chart a course toward a better world. CSIS is a bipartisan, nonprofit organization headquartered in Washington, D.C. The Center’s more than 200 full-time staff and large network of affiliated scholars conduct research and analysis and develop policy initiatives that look to the future and anticipate change. Since 1962, CSIS has been dedicated to finding ways to sustain American prominence and prosperity as a force for good in the world. After 50 years, CSIS has become one of the world’s preeminent international policy institutions focused on defense and security; regional stability; and transnational challenges ranging from energy and climate to global development and economic integration. Former U.S. senator Sam Nunn has chaired the CSIS Board of Trustees since 1999. John J. Hamre became the Center’s president and chief executive officer in 2000. CSIS was founded by David M. Abshire and Admiral Arleigh Burke. CSIS does not take specific policy positions; accordingly, all views expressed herein should be understood to be solely those of the author(s). Cover photo: Women in Bongouanou, Côte d’Ivoire, during a prenatal medical consultation. Photo ID 509486. 27/01/2012. Bongouanou, Côte d'Ivoire. UN Photo/Hien Macline, (www.unmultimedia.org/photo/); http://www.flickr.com/photos/un_photo/7065765017/. © 2012 by the Center for Strategic and International Studies. All rights reserved. Center for Strategic and International Studies 1800 K Street, NW, Washington, DC 20006 Tel: (202) 887-0200 Fax: (202) 775-3199 Web: www.csis.org embedd improving maternal mortality and other aspects of women’s health the united states’ global role Phillip Nieburg1 Societies that have achieved the lowest levels of maternal mortality have done so by preventing pregnancies, by reducing the incidence of certain [pregnancy] complications, and by having adequate facilities and well-trained staff to treat the complications.2 Introduction Over the past several decades, the world has witnessed some astonishing global health success stories—from the eradication of smallpox to the expanding control of other vaccine-preventable diseases to the widespread provision of effective treatment for HIV/AIDS to millions of people. Yet, for all these public health and medical advances, a startling number of women still die each year from causes linked to pregnancy and childbirth: 287,000, according to the most recent consensus estimates.3 That’s nearly 800 women per day; more than 30 every hour. Eighty-five percent of these deaths occur in sub-Saharan Africa and South Asia. Many if not most are thought to be avoidable given adequate maternal access to emergency obstetric care (EmOC). Over the last 25 years, some countries, including some that are resource poor, have made striking progress in reducing maternal mortality, but many others still lag behind and are unlikely to achieve the country-specific 2015 women’s health targets established in 2000 under the Millennium Development Goals.4 1 Phillip Nieburg, MD, MPH, is a senior associate with the CSIS Global Health Policy Center. He was accompanied on this mission by Janet Fleischman, also a CSIS senior associate. 2 James McCarthy and Deborah Maine, “A Framework for Analyzing the Determinants of Maternal Mortality,” Studies in Family Planning 23 no.1 (January/February 1992): 23–33. 3 World Health Organization (WHO), Trends in Maternal Mortality: 1990–2010: WHO, UNICEF, UNFPA, and The World Bank Estimates (Geneva: WHO, 2012), http://whqlibdoc.who.int/publications/ 2012/9789241503631_eng.pdf. 4 In 2000, the United Nations, concerned about limited progress being made in advancing global reproductive health goals, had included “Improve women’s health” as one of eight new Millennium Development Goals (MDGs) intended to address a series of important global development challenges by 2015. Details of these goals—and progress toward them—can be found at http//:www.un.org/millenniumgoals/bkgd.shtml. | 1 In response to this ongoing tragedy, the United States has recently begun taking an increasingly visible role in global efforts to reduce maternal mortality, seeking to create new governmental and public-private partnerships toward that end. In June 2012, Secretary of State Clinton delivered a major speech in Oslo, Norway, highlighting the huge global burden of maternal mortality, and announcing U.S. participation in a new initiative called Saving Mothers, Giving Life, a five-year endeavor designed to help provide needed emergency care to women in labor, delivery, and the first 24 hours postpartum.5, 6 The United States will contribute $75 million to this public-private collaboration, which will initially focus on maternal mortality challenges in selected districts of two sub-Saharan African countries, Uganda and Zambia. The Saving Mothers, Giving Life collaboration will also be supported by direct and in kind resources from the government of Norway ($80 million), the Merck for Mothers Program7 ($58 million), the American College of Obstetrics and Gynecology (technical support), and the Every Mother Counts campaign (public outreach).8, 9, 10 In April 2012, before the Saving Mothers, Giving Life program was announced, a small CSIS delegation traveled to Tanzania to explore constructive roles that the U.S. government and other external donors could play in improving women’s health and reducing maternal mortality in Tanzania and elsewhere.11 This report on the maternal health aspects of that visit is intended for 5 Janet Fleischman, “Saving Mothers, Giving Life: Attainable or Simply Aspirational?” CSIS, June 2012, http://www.smartglobalhealth.org/blog/entry/saving-mothers-giving-life-attainable-or-simply-aspirational/. 6 Hillary Clinton, “A World in Transition: Charting a New Path in Global Health” (remarks presented in Oslo, Norway, June 1, 2012), http://www.state.gov/secretary/rm/2012/06/191633.htm. Saving Mothers, Giving Life is a public-private collaboration between the governments of the United States and Norway, Merck Pharmaceuticals, the American College of Obstetrics and Gynecology, and the nongovernmental organization Every Mother Counts. See http://savingmothersgivinglife.org/about_smgl.html. 7 See the Merck for Mothers collaboration announcement at http://www.merckformothers.com/ newsroom/smgl_announcement_june.aspx. 8 The program will initially focus on addressing the risks of labor and delivery in four districts each in Uganda and Zambia. Specific interventions will be intended to improve access of pregnant women to emergency obstetric care (EmOC) both by increasing the staff skills and other medical resources available at existing health facilities and by addressing the various transportation and other access challenges that have proven to be obstacles to adequate care for largely rural populations. U.S. resources will come from the President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. Agency for International Development (USAID), and the Center for Disease Control and Prevention (CDC), the latter with reprogrammed funds. 9 Fleischman, “Saving Mothers, Giving Life.” 10 The Every Mother Counts campaign is a U.S.-based advocacy project that works to support global maternal mortality reduction goals by educating U.S. and other audiences on the challenges facing women and girls worldwide. It was founded by Christy Turlington Burns, a writer, filmmaker, and model. See http://everymothercounts.org. 11 The CSIS delegation focused on issues of gender-based violence, integration of family planning into PEPFAR and other HIV/AIDS programs, and women’s health and maternal mortality. See Janet Fleischman, HIV and Family Planning Integration in Tanzania: Building on the PEPFAR Platform to Advance Global 2 | improving maternal mortality and other aspects of women’s health those persons less familiar with the technical and organizational details of addressing maternal mortality for use as a guide to some of the complex challenges inherent in addressing these issues, as well as to recommend steps to increase the odds of success. The report uses data and observations from Tanzania and many other countries to describe the specific burdens on women’s health that are associated with pregnancy, labor, and delivery. It discusses many of the major interventions currently being planned and/or implemented by developing country governments and their supporters, and it identifies key challenges for improving maternal mortality and women’s health overall in developing countries. The report concludes with specific recommendations for long-term U.S. policy priorities, including: 1. A comprehensive U.S. government approach to women’s health that rests on sustained high-level U.S. leadership in supporting access to emergency obstetric