Developing World: Maternal and Neonatal Mortality
(9 years, 10 months ago)
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Baroness Hayman
To ask Her Majesty’s Government what progress has been made in reducing maternal and neonatal mortality in the developing world; and what plans they have to build on this work post-2015.
Baroness Hayman (CB)
My Lords, I am grateful for the opportunity to introduce this debate, and delighted that noble Lords from all Benches of your Lordships’ House are planning to contribute on this important issue. I declare my interests in health and development, particularly my chairmanship of the external advisory group of the Centre for Maternal and Newborn Health at the Liverpool School of Tropical Medicine.
It was in this role that last year I visited Zimbabwe and saw for myself the power of the Making it Happen programme run by the centre in 11 countries, supported by DfID. I saw UK volunteers, an obstetrician and a midwife, together with Zimbabwean master trainers who had been through the course before, supported by the country’s Ministry of Health, running the course for Zimbabwean health workers, giving them the skills to save the lives of mothers and babies and to pass on those skills to their colleagues to ensure sustainability and improved services countrywide.
I will step back from the specific to address the scale of the problem. The statistics are chilling. Some 300,000 women die every year; 800 women die every day in pregnancy and childbirth; 50 will die in the course of this short debate. There are an estimated 2.6 million stillbirths and 3 million neonatal deaths every year; half of those neonatal deaths occur in the first 24 hours of life. A child dies somewhere in the world every five seconds, overwhelmingly of preventable causes.
These maternal and neonatal deaths are not evenly distributed. The maternal mortality ratio shows the highest discrepancy: the greatest gap between high and low income settings of all international health indicators. In the UK, the maternal mortality ratio is eight per 100,000. In Sierra Leone, it is 110 per 100,000. That is the last figure that we have; I hate to think what the figure will be for the last 12 months when the ravages of Ebola have put into abeyance the most basic health services that were available in the past. The average for neonatal mortality in developed countries is 3.7 per 1,000 live births; in southern Africa and south-east Asia it is 10 times that; 99% of all maternal deaths and 98% of all neonatal deaths occur in low or middle-income countries.
Within developing countries there are wide variations, with the poorest, the youngest, the least educated, and rural women most at risk. The deaths are not the end of the story. For every woman who dies in childbirth, it is estimated that 20 to 30 live but suffer lifelong morbidity such as fistula. The health and survival of babies is dependent on the health and survival of mothers, not only in the quality of antenatal, intra-partum and post-partum care, but evidenced by the fact—I have lost the reference for this statistic, but I am sure someone will tell me—that a motherless child is 10 times more likely to die in the first two years of its life than a child who has a mother to care for them.
It was the recognition of this tsunami of suffering and the obstacle to development that the figures represent—because we all know how crucial women are to development—that led to the introduction of millennium development goals 4 and 5, of reducing child deaths by two-thirds and maternal deaths by 75% by 2015. When the Minister comes to answer the question posed in the title of this debate, I am certain that she will outline the considerable progress that has been made since 1990.
I pay tribute to the work that has been done in developing countries by DfID and other international agencies in just about halving those deaths. The figures have been helped of course by the progress in other MDGs, for example in relation to HIV/AIDS and malaria, and perhaps point us again, looking forward, to the importance of joined-up healthcare and healthcare for all.
However, it is disappointing that the progress that has been made has, again, not been evenly distributed, and that some of the countries that have the worst figures, and which need the greatest improvements, are ones that have seen the least change in their statistics. I ask the Minister to address the issue of how, post-2015, we attend to the unfinished business in the millennium development goals and ensure that we do not take our eye off the ball in these hugely important areas where we need to make sustained efforts in order to continue with the progress made so far.
I have not said a lot so far about the causes of maternal and newborn mortality, and how this terrible toll of death and suffering can be reduced. That is partly because when I asked a local expert for help in preparing for this debate and what she thought I ought to stress and what ought to be said, she shrugged her shoulders and said, “There is nothing new to say. We know what the issues are and we know how they can be addressed. What are needed are the resources and the political will to do it”.
You can go through the list of causes of maternal and newborn death: poor nutrition, existing medical conditions—which are often the diseases of the poor, such as malaria—unsafe abortions, infections, eclampsia, haemorrhage and obstruction in labour. The last three of these can be addressed by specific programmes of maternity care, but the first are much wider issues relating to water and sanitation, education for girls, an end to child marriage, immunisation programmes, and access to family planning and antenatal intra-partum and post-partum care from trained and skilled birth attendants. That is where programmes such as Making a Difference can have profound effects: in the first phase of those programmes, maternal death rates in areas where they had been implemented reduced by as much as 50%. The decision we have to make globally is about the priority that we give to the quality of women’s lives and the numbers of women’s deaths.
In the early 17th century, Joseph Hall, who was then Bishop of Exeter, wrote:
“Death borders upon our birth, and our cradle stands in the grave”.
That is no longer true in this country. It need no longer be true in the developing world. But to stop it being the reality for millions in that world, we have to put the resources and the priority into work to reduce maternal and neonatal deaths.
Lord Bourne of Aberystwyth (Con)
As the debate gets under way, I respectfully remind noble Lords that this is a time-limited debate.
Baroness Hodgson of Abinger (Con)
My Lords, nearly every minute of every day a woman dies from complications in pregnancy and childbirth. Yesterday 800 women across the world died; 800 will die today and every day until the end of the year and into next. On average, 9,000 babies will die at birth or in the first week of life each day of this year too. In this day and age these are truly shocking figures.
I congratulate the noble Baroness, Lady Hayman, on having secured this debate which encompasses two of the most important millennium development goals—to reduce child mortality and to improve maternal health. Of course, these two goals go hand in hand and I am heartened that the title of this debate recognises it.
There has been improvement. Since 1990, maternal mortality has declined by nearly half. Although progress has been made in all developing regions, as we have already heard, there are vast geographical disparities and it is now estimated that 99% of maternal deaths occur in developing countries. In 2013, the maternal mortality ratio in developing countries was 230 per 100,000 live births, compared to 16 per 100,000 in the developed world. For example, one woman in 30,000 dies as a result of pregnancy and childbirth in Sweden, whereas in Afghanistan it is about one in six. So many of these deaths are preventable. These women will not have had the pain relief and epidurals that we have come to expect here. Many will have had to endure many hours of excruciating and unbearable pain before they die.
Neonatal mortality rates have also declined significantly over the past 20 years, but to have between 3 million and 4 million babies a year currently dying is truly appalling. Cocooned in the Palace of Westminster, we might find these overwhelming impersonal statistics numbing, but we should remember that each and every one of these deaths is a devastating tragedy for those involved. It is a tragedy for the children who lose a mother—and children who have lost their mothers are 10 times more likely to die prematurely—and a tragedy for the mother who loses a baby. In the West these losses are mercifully rare but, having lost a baby at birth myself, I know personally that it is a very hard thing ever to come to terms with.
For every woman who dies, at least 20 more suffer complications which may leave them with lifelong crippling disability and pain. Lack of obstetric care may result in fistula, resulting in them being shunned by their families and the community. Traumatic births can cause postnatal depression—something rarely mentioned in the context of developing countries. Today in the UK, 10% to 20% of women develop a mental illness during pregnancy or within the first year after having a baby. With the right help, women can recover but, without that help, they may never be able to function properly again. For a baby, even slight oxygen deprivation at birth may cause life-changing damage—either physical or mental.
Many of these deaths are avoidable but, to ensure the fundamental well-being and survival of both mothers and babies, every woman needs access to a trained doctor or midwife. In countries such as Afghanistan, only 14% of births are attended by a health worker. Every year, across the world, 46 million babies are delivered without any skilled assistance.
I have seen the challenges from my visits to various countries. For example, I remember visiting the district hospital in Koinadugu in Northern Province, Sierra Leone a few years ago. There was only one doctor in the hospital, who was also the district health administrator. He explained that some of the villages in the district were 100 miles away from the hospital and there were no roads. Although there was a system of outlying clinics, none had doctors and most had no trained nurses either. The radio system to them from the hospital was broken. There are similar tales in many other developing countries. So it is not just about ensuring that there are enough doctors and midwives in these countries; it is also about ensuring that the medical care that is so vitally needed can be reached.
Harmful traditional practices such as FGM and early marriage, all too prevalent in some developing countries, also contribute to maternal and child mortality. Lack of adequate nutrition can also be a cause. Lack of gender equality impacts, too. For example, there are clear connections between women’s lack of access to education and reproductive rights and health. In some countries, girls commonly have to leave school due to pregnancy or for early marriage—that is, if they have attended school at all. I recently visited Mali, which has one of the highest child marriage rates in the world. Half of the girls there will be married before they are 18. In addition to greater vulnerability to domestic violence and the contracting of diseases, these child brides are more likely to bear children before they are physically ready, thus exposing them to extreme risk. Newborn baby deaths are also 50% higher when born to those under 20.
Women need to be empowered in a wider cultural sense by having control over their sexual and reproductive activity. It is estimated that 215 million women in the developing world want to delay or avoid pregnancy, with as many as 50% of pregnancies being unplanned and 25% unwanted. Having to have baby after baby wears a woman out, with each pregnancy multiplying her chance of dying from complications. It is estimated that a third of these deaths could be avoided if women had access to contraception services, which would help avert unintended and closely spaced pregnancies and reduce instances of unsafe abortions. This is because one-quarter of all pregnancies end in abortion and 19 million of those abortions are unsafe, resulting in 68,000 deaths per year and many women suffering complications and infections. So the provision of proper contraception is crucial in improving reproductive health and tackling maternal mortality.
I particularly welcome the debate today, as in spite of the improvement of the last 20 years the situation is still unacceptable. We need to be resolute in tackling the causes in developing countries because we still have a long way to go until every woman and child across the world receives the care that we, in the western world, take for granted.
Baroness Kinnock of Holyhead (Lab)
My Lords, I, too, thank the noble Baroness, Lady Hayman, for introducing this debate and for doing so in such a compelling and expert way.
In large parts of the world, poverty means that great numbers of women die from a lack of family planning, an inability to negotiate the number and spacing of children, the lack of money to pay for skilled birth attendants or emergency obstetric care, and violence. In spite of some welcome progress, it is clear that MDG 5, on reducing maternal mortality and achieving universal access to reproductive health, is far from being fulfilled. However, as affirmed by the UN Commission on the Status of Women, the elimination of preventable maternal mortality is possible in the next decade but it will, clearly, require a major scaling-up of our efforts. Does the Minister agree that sexual and reproductive healthcare for women and girls should be a specific priority, separated from maternal health, so that its allocation and impact can be properly measured? Is the Minister aware that around only 1% of ODA is currently allocated to family planning?
DfID has also committed to,
“enable 10 million more women to access family planning (of which 1 million will be girls aged 15-19)”.
How confident is the Minister that this objective can be met, since only 4,966,000 have been reached to date? Does the Minister agree that, as DfID spending on humanitarian assistance is increasing, it is vital that a comprehensive package is offered in emergency settings, such as conflicts and disasters, and that this should include access to sexual and reproductive health?
The UN high-level panel established to prepare the post-2015 agenda for action estimates that 800 women die every day from complications related to pregnancy and childbirth and, according to the WHO, 99% of those maternal deaths occur in developing countries. In addition, medical experts testify that, globally, every year there are about 80 million unplanned pregnancies and 20 million unsafe abortions with the result that, as Marie Stopes International points out:
“Worldwide, one woman dies every 11 minutes from an unsafe abortion”.
Unsafe abortion is a major cause of maternal mortality and remains a major public health and human rights concern. Being able to make an informed choice and take control of your own reproductive health is surely a basic right. Does the Minister agree with the view that Governments and donors need to prioritise what women want, rather than what they feel most comfortable with doing and providing? Such a change is urgent. I remember talking to Beth outside her home in rural Tanzania. Such were the perils of childbirth that before she went into labour she would say goodbye to her children. Giving life should surely not mean taking such a risk.
A post-2015 assessment says that aiming to reduce newborn mortality by 70% will prevent 2 million child deaths every year. Such evidence highlights the urgent need to provide expectant mothers with nutrients, protection against disease, nursing care, clean water and hygiene facilities. All these initiatives can save precious lives and are taken for granted in the developed world. No girl should die giving birth and no child should die because its mother is too young. Each year around 1 million babies born to adolescent girls die before their first birthday.
These issues go beyond family planning. Campaigns and condom distribution are irrelevant to women and girls who simply do not have the power to make the decisions. A country’s current status and future prospects are clearly illuminated by examining, for instance, the lifetime risk of maternal death, the percentage of women using modern contraceptives, women’s literacy rate, their participation in national growth and the enrolment of girls in school.
The reality is that gender inequality remains a major propellant of poverty and women’s marginalisation, and a basic cause of underdevelopment. Faced with that reality, it is clear that little will change until the underlying root causes of discrimination are plainly and publicly identified as gender inequality and pervasive, discriminatory norms. Religious, cultural and social barriers impose overt discrimination that stands in the way of women’s freedom to choose.
One hundred and ninety-three Governments are currently gearing up for the UN discussion, at September’s annual meeting, on priorities for the next decade and a half. Currently, there are 17 goals and 169 targets. However, we can safely say that there will be a stand-alone goal on gender equality, women’s rights and empowerment. This will include universal access to sexual and reproductive health, and rights to be mainstreamed across all other goals. The task is to prevent an estimated 640,000 newborn deaths and 150,000 maternal deaths each year, which will result in 600,000 children having to grow up without a mother. When motherless children are 10 times more likely to die within two years of their mother’s death, the urgency is graphically obvious.
To achieve such advances we will indeed need political leadership. When fundamental rights are upheld, women, girls and young people can thrive. They can gain education, get better jobs with better wages and therefore reach their full potential. That objective is essential and, I believe, achievable. It will serve every interest. It must gain active support. The British Government have a duty to take the lead in that mission.
Lord Patel (CB)
My Lords, I join the noble Baroness, Lady Hayman, in the tribute that she paid to DfID for the work that it has done and continues to support in areas of reducing maternal and child mortality. I emphasise that in the hope that DfID will not now stop but put extra vigour in joining other partners in delivery until we achieve the goals.
As has already been said, the statistics—which will be cited by others—are horrendous. A woman giving life should neither die nor go through childbirth only to have the heartbreak of losing her child at birth or in infancy. The noble Baroness, Lady Hodgson, described her experiences, which I well understand. Yet for many mothers and their children this is a reality. Three hundred thousand women die every year during pregnancy. For children, the statistics are worse. There are 131 million births a year; of these, 6.3 million children die before the age of five. That is 17,000 deaths of children every day. One million babies are stillborn. Two million die in the first week of life, and for 1 million babies the day of their birth is the day of their death. While progress in reducing maternal and infant deaths has been significant over the past two decades, many millions continue to die, and 223 million children under five died between 1990 and 2013. Four out of five deaths of children aged under five occur in sub-Saharan Africa.
While the number of deaths of children under five has declined, the decline in the number of deaths around birth and in the first month of life is not so striking. Neonatal deaths now account for 44% of deaths of children under five. There has been no noticeable reduction in neonatal deaths. Some interventions focused on the 24 hours after birth hold great potential for reducing maternal and neonatal deaths. We know the causes of death and how to prevent them, but we have not succeeded in delivering health interventions widely and consistently throughout the world or in developing sustainable health systems.
Two-thirds of neonatal deaths occur in 10 countries, and 48%—nearly half—occur in four countries: India, China, Nigeria and Pakistan. Two-thirds occur in only two countries, India and Nigeria, and both of them are capable of developing health systems that would stop them, so what must we do to encourage them to strengthen their health systems?
The causes of neonatal deaths are pre-term births, complications at birth, infections and sepsis and congenital abnormalities. Basic, cost-effective care in the first hour after birth results in significant reductions in maternal and neonatal mortality. For example, breastfeeding in the first hour of life reduces deaths by 40%, yet only 50% of newborns are breastfed in the first hour of life, particularly in vulnerable parts of the world. Skilled attendants at birth and the use of a maternal and neonatal checklist which includes simple tasks, such as cord care, dramatically reduces neonatal mortality, yet 44% of women in some countries do not have skilled attendants, and even when there are attendants at birth, simple interventions are not delivered. For example, only 10% of babies delivered by skilled attendants received seven key neonatal interventions, so we must ask why, even when there are skilled attendants, they do not happen. Hence, we have developed a checklist for maternal and child health at the time of birth to try to make sure that those interventions, including breastfeeding, can be delivered.
The charity, SafeHands, of which I am a patron, as is the noble Baroness, Lady Kennedy of The Shaws, who is not in her place, tries to use education using visual media in rural villages in Ethiopia and other countries to deliver messages about the importance of basic care and attendants at birth, which can have dramatic effects.
What of the future? The world needs to fulfil the promise made to the children of this world in 2000. The MDG 4 target will not be met in 2015. At the current rate, it will not be met until 2026. We need a new commitment, not just the targets of 2015, even if we could meet them in 2026. We need a new commitment to children going beyond MDG 4 that by 2035 every country will see a neonatal death rate of 10 per 1,000 births and a stillbirth rate of 10 per 1,000 births. The challenge could be 20 by 2035, to mothers and their babies underpinned by helping to establish sustainable health systems.
The UK Government have done so much to advance these causes and lead the world. What commitment will they make beyond 2015 towards efforts to reduce maternal and childhood deaths?
The Lord Bishop of Derby
My Lords, I too congratulate the noble Baroness, Lady Hayman, on securing this debate and on introducing it with such expertise and such a challenging sense of the statistics. Millennium development goals 4 and 5 are not being met and, as other speakers have said, the consequences are horrendous. My contribution will be from my own experience working with people at the grass roots, and I will then tease out what the implications of that experience should be.
I work in the diocese of Derby, in England, and we are twinned with the Church of North India, which extends from Calcutta to Mumbai—the whole of north India is twinned with our diocese in an ecumenical link. I work with people in a number of Indian communities where this issue is enormous. In 2012, one-third of global neonatal deaths happened in India. The highest rate of first-day mortality is in India. That is the context in which we are working with our partners, through whose eyes we discern some factors.
The first, as other noble Lords have said, is poverty. People just do not have the means to call medical help and there is no local infrastructure available anyway even if they could. That kind of poverty is a major factor. The second factor is the lack of education about basic hygiene. I visited slums in Calcutta with the Cathedral Relief Service, which trains very young girls of 10 to 12 to wander in and out of people’s houses, giving good advice about hygiene and childcare. This helps families learn good practice in an unthreatening way and will produce a new generation of young mothers with those skills. This is a practical, grass-roots response.
My colleagues in India would say that the third factor is that a lack of respect for women and girls is behind these terrible statistics. The attitude so often is that this is their role—illness is not taken seriously—and their job is to run the household. New mothers are expected just to get up and carry on with things. Fourthly, in the urban areas, the issue is not so much a matter of the infrastructure being hundreds of miles away but that whole families live on pavements and give birth there. I was in Calcutta in December and saw families living in the street with no resources, cutting the cord with an ordinary knife because that was all that was at hand.
That was a snapshot of some of my experiences; what are the responses? I work with ISPCK—the Indian version of the publishing house—and the Cathedral Relief Service in Calcutta. As the noble Baroness, Lady Kinnock, was hinting, they say that the key is to have strong, empowered women. Research by the Cathedral Relief Service in Calcutta shows that 63% of pregnant women in the slums are anaemic. That is an appalling starting place. I visited a slum where they had just invented a green goo to give to people to build up their resources—I had to taste it, and it was a really testing moment in intercultural activity. People have to take this kind of local initiative to build, literally, physically strong women.
Women have to be empowered, too, and many people in development know that it is by building up women that families survive and have structure and leadership. We spend a lot of time in our diocese raising funds to provide sewing machines for women so that the family has a livelihood. This year, we are raising funds to create businesses for recycling in Delhi, where all the waste from industrialising India needs dealing with. It is only by giving women that kind of strength and security that they will be able to deal with some of the issues about family planning and their self-respect and standing in the community.
Other things that we do with our partners include running education and immunisation programmes, as well as doing home visits. We show films in the slums, and some villages have health days, when volunteers go out and gather people around. So what are the implications that I am learning? The key one is partnership. There is a partnership between the people of Derbyshire and people in the slums and rural areas of India around this issue, which provides practical help and tries to empower women and provide infrastructure.
I am privileged to be a trustee of Christian Aid, which specialises in partnership working with local agencies. We work in Kenya, Malawi and Bangalore, in India, and there are lots of stories that I could tell—like the ones from Derbyshire—of partnership working. Most exciting is our partnership at the moment with DfID. The Minister came to the Christian Aid carol service and launched a match funding scheme for a project in Kenya on this very topic. We should congratulate the Government on their approach to partnering with organisations such as Christian Aid, which have a lot of expertise on the ground and grass-roots connections and can deliver real change. I am proud of the way that our Government are investing in that. Clearly, we can always do more and clearly we need millennium development goals that will challenge the Government more, but I record on behalf of Christian Aid our positive experience of working with DfID and what a good job comes out of it.
I finish with two questions for the Minister. If developing countries need encouragement to ensure provision for maternal healthcare, what can the Government do to up their game about partnership with those who have grass-roots contacts? That is where we need to operate—with those who are excluded at grass-roots level. We need to connect with those people. How can the Government up their game, working in partnership and investing their funds, while using their influence with other Governments for grass-roots activities?
Secondly, we all know that a lot of problems in developing countries are caused by the unsatisfactory tax base. So much of what could be raised by taxation to provide money for health and other infrastructure is shifted out of the country by the way that corporations operate financially. Both the Prime Minister and the Chancellor have spoken out against this practice, commendably, and we have had debates in this House about it. I would be interested to know what the Minister thinks about the part that getting a better tax structure in developing countries plays if we are to equip people in their own places to take up this work and meet the challenge.
Baroness Tonge (Ind LD)
My Lords, I, too, thank the noble Baroness, Lady Hayman, for bringing this matter to the attention of the House. As chair of the All-Party Parliamentary Group on Population, Development and Reproductive Health and president of the European forum of the same name, it is a subject that has occupied most of my waking hours in the last few years. Indeed, sexual and reproductive health occupied the whole of my professional life before I was elected to the other place.
I am constantly dismayed when I talk to colleagues about maternal mortality and family sizes. I get back the same old mantra. “Oh”, they say, “we can’t do anything about it—people in developing countries need big families because they have to have people to look after them in their old age and they need people to work in the fields. They’ve got to have big families—you mustn’t prevent them from doing that”. We have all been working hard in this Government, and in DfID in particular, to convince those Members that that is no longer the truth.
We have heard a lot of statistics, and I welcome their repetition; we should have them fixed in our head. But in fact maternal mortality is reducing—there is some good news. It has reduced by some 50% in the past 20 years; now around 250,000 women die per annum. That is still far too many, but it is reducing. With that figure goes the estimate that 2 million neonatal deaths occur per annum—and we know that they are linked.
We must also remember, as all Members have pointed out, that it is not just maternal deaths. They hide the fact that maternal morbidity and terrible conditions after childbirth, such as fistula—of which I know the noble Lord, Lord Patel, has had such experience and on which he has done so much incredible work—are also very important and account for millions of women being unable to take proper part in family life and look after their families properly because of childbirth. All are due to lack of proper medical and obstetric care and to other factors such as too-early marriage, child marriage, forced marriage, violence in marriage—but most of all, in my view, they are due to a lack of family planning, which enables women to control their own bodies and voluntarily space the number of children that they have.
We know that more than 2 million women in developing countries would use birth control entirely voluntarily if they had access to it. That is a fact. It has been disregarded in the past, but thanks to the efforts of parliamentarians here, Governments such as our own, and the Bill and Melinda Gates Foundation, a great effort is now being made to get family planning supplies out to those women who need them.
In 2012, our own Government—and I am very proud to mention and applaud this—held a great family planning summit. Pledges were made from all over the world and progress has been made. Since then, 8.4 million more women are now able to control the number of children that they have: that is in a report from the organisation Family Planning 2020, which was set up to monitor the pledges given at the summit and see that they were being delivered. This is all happening despite tradition, despite their religion, despite all the excuses given in the past—especially the one that we need children to look after us in or old age. I am constantly telling my children that.
I hope that our colleagues in both Houses will take note and realise that maternal health—and family planning in particular—is the way to sustainable develop -ment. The World Bank, no less, has pointed out that sustainable development and a steady rise in a country’s GNP follow a reduction in family size or fertility rate in that country. We know now that it is not the other way around. Sexual and reproductive health and rights, including family planning, are essential for sustainable development. We are pretty sure, too, that fewer people will mean less environmental degradation; my all-party group is doing an investigation into this subject at the moment.
There are other advantages for us, too, when this happens. Less international aid will be required in the long term; there will be bigger markets for our goods, if that interests noble Lords; and—dare I say it—there will be less migration from those countries for a better life in the West. Let us say that loud and clear: if they do not listen to our arguments on maternal health and reproductive health and rights, tell them that; tell that to UKIP and tell those people who disregard the importance of international development.
I am still concerned that this message is not being taken as seriously as it should be by the United Nations body deciding on the action needed after 2015, as was touched upon by the noble Baroness, Lady Kinnock. At that time, the millennium development goals should have been achieved. We know that MDG 5 on maternal mortality will not be achieved: there is not a hope.
The European forum of which I am the president—I want to tell your Lordships about this—has Members of Parliament from 25 countries in Europe and beyond. It includes members from Russia and Turkey; it is not just the European Union. We liaise with, and have encouraged the formation of, similar parliamentary groups to ours and similar forums in Australasia and Africa. All those parliamentarians all over the world are having meetings and making declarations on the very things we have been talking about this afternoon—impressing on their Governments, when they go back home from their meetings, that this is the line that they must take, both in their own country and internationally.
The international parliamentary conference on the implementation of all these declarations, meetings and forums that have taken place among parliamentarians was held in Stockholm earlier this year. Some of us went from our all-party group. This conference agreed that sexual and reproductive health and rights—remember all those elements—should be high on the list for the post-millennium goals agenda. That was only after lobbying the office of the UN Secretary-General after an unsatisfactory interim report was published that did not mention sexual rights or sexual health. It mentioned just reproductive health.
We finally got some movement. We lobbied, and the parliamentarians got together and wrote letters and started making a fuss about this, after all our efforts. I am glad to say that last week we heard from the Secretary-General’s office that the final version of what is called the synthesis report—sorry about the terminology; it is not mine—which was released on Christmas Day, of all days, included the words,
“women’s sexual and reproductive health and reproductive rights”.
That has moved us forward quite a bit: it is mentioned, that is good, they are looking at it. However, the word “rights” still applies only to “reproduction” and not to “sexual”, which means that there is disagreement and concern about a woman’s right to safe abortion, which was mentioned by several speakers. Even after rape, we are still unsure whether women can get a safe abortion. There is no protection against FGM, for example. So we must keep putting on the pressure.
I am sorry, I have nearly finished. I fully understand that these are sensitive issues and I hope that the Minister can tell us that our Government—who have worked so hard on these issues in the last five years and held two special conferences this year alone to deal with FGM and sexual violence in conflict—will insist, at the final conference in September at the UN on the post-MDG agenda, that these issues will be dealt with in full.
Sexual and reproductive health and rights are human rights. We talk about the empowerment of women very glibly, but we cannot ensure that until we allow women to have control over their own bodies. We simply cannot. Women all over the world are depending on us to release them from the position to which they are condemned. We must not let them down.
Lord Alton of Liverpool (CB)
My Lords, we are all greatly indebted to my noble friend Lady Hayman for instigating this debate and for the way that she introduced it. As she told us, my noble friend is chair of the external advisory group of the Liverpool School of Tropical Medicine’s Centre for Maternal and Newborn Health. Her work for the school has given it very great encouragement. For more than 30 years I have been privileged to be associated with the work of the school and serve as an honorary vice-president. The centre designs and implements innovative healthcare packages, and offers unique expertise in research and in developing evaluation frameworks. It works collaboratively and strategically with Governments and global agencies, saving the lives of women in countless countries, along with the lives of their babies.
Professor Nynke van den Broek, who is head of the Centre for Maternal and Newborn Health, graphically sets out the scale of the challenges that face developing countries in reducing maternal and neonatal mortality. She says that an estimated 300,000 women die each year from complications in pregnancy and childbirth and—as the noble Baroness, Lady Tonge, said a few moments ago—this represents a decline. The school says it is about 45% overall since 1990. However, this should not lead us to any kind of complacency because it still equates to a woman dying every 90 seconds, or 800 women a day. There are also at least 2.6 million stillbirths every year and an additional 2.9 million neonatal deaths. At least 43% of deaths in children under five occur in the first month of life.
The World Health Organization says that 99% of all maternal deaths occur in developing countries. Inevitably, this loss of life is at its most acute in rural areas and—as the right reverend Prelate the Bishop of Derby said—in poorer communities. UNICEF reminds us that more than 50% of women still deliver without the assistance of skilled health personnel, with 80% of maternal deaths caused by direct obstetric causes. Pivotal to addressing this shocking and avoidable loss of life is the challenge of improving the health and nutrition of mothers and providing access to good-quality support services for mothers-to-be and newborns, before and after birth.
At a personal level, two decades ago I was struck by what a difference those factors could make. While working in Namibia, my sister gave birth to my niece at 32 weeks’ gestation. My niece weighed less than two pounds and no baby as small as that had previously survived in Namibia. I was told that important to her survival was her mother’s breast milk and the antibodies it contains, but obviously she was too small to be able to suckle. There was no electric breast pump available at the hospital. I was able to buy one and ship it out. How different the outcome would have been if she had been living in the bush or a remote village without access to resources. That is surely the challenge we have to address.
Consider this tale of two countries: 2013 data highlight UK maternal mortality rates as standing at eight deaths in every 100,000, with three neonatal deaths for every 100,000 live births. By contrast, in Zimbabwe—visited by my noble friend—there are 470 maternal deaths in every 100,000 and 39 neonatal deaths for every 100,000. The vast majority of stillbirths, newborn deaths and maternal deaths occur around the time of birth and in developing countries. Ultimately, the health and survival of babies depends on the health and survival of mothers and that requires resources.
It has, of course, been crucial that millennium development goals 4 and 5 have helped to shape the agenda for action to improve these health indicators. That progress has been made is borne out in the report Financing Global Health 2013 from the Institute for Health Metrics and Evaluation. It noted a welcome increase of nearly 18% in development assistance for maternal, newborn and child health. Although I join others in congratulating DfID on the role it has played in this, nevertheless the spending per live birth remained at just £32 per child.
Even where death does not occur, failure to provide resources and care at this crucial moment in a woman’s life can have, as we have heard, long-term consequences. For each maternal death, an estimated 20 to 30 women live but suffer lifelong morbidity including a fistula, which my noble friend Lord Patel has done so much work to tackle and was mentioned by my noble friend Lady Hayman. In addition, there is chronic infection, anaemia and infertility. The Liverpool School of Tropical Medicine is currently working with the World Health Organization to develop new tools to provide more detailed data—something that DfID might want to support.
Improving the availability and quality of data helps to capture and understand the reasons for maternal and neonatal deaths, and to develop the necessary initiatives to prevent deaths. Digging deeper into the currently available statistics, it starts to become clear where we should concentrate our resources and our efforts. Baseline surveys under the Liverpool School-led and DfID-funded Making it Happen programme show that across 11 countries early newborn care packages are simply not consistently available. Out of 749 hospitals and health centres, only 173 were able to provide the required emergency obstetric care package, which is 23.1% or less than one in four. A study of reasons for unavailability of the care package shows that in 17% to 75% of cases there was lack of functioning equipment; in 13% to 17% of cases the reason was lack of a staff cadre—doctors or senior midwives—able to lead the team or provide the more technical aspects of care; and in 2% there was a reported lack of drugs. Not surprisingly, then, sub-Saharan Africa accounts for 62% of all maternal deaths, followed by south Asia with 24%.
As my noble friend Lord Patel reminded us, two countries stand out: Nigeria and India. India accounts for 17% and Nigeria 14% of the total. The right reverend Prelate told us of his experiences in India. It is one of the world’s greatest nations, yet in its treatment of women, from conception to death, India justifies its title as the land of paradoxes. A 2012 report by the United Nations Department of Economic and Social Affairs found that the ratio of boy to girl deaths is severely skewed. Between 2000 and 2010, 100 girls aged one to five died for every 56 boys. Putting that into plain language, an Indian baby girl is almost twice as likely as an Indian boy to die before the age of five, and the problem seems to be getting worse. In 1961, 976 girls were born for every 1,000 boys, and in 2011 that number was 914. The horror stories that have filled Indian papers, describing bodies of baby girls decomposing in heaps by refuse pits or being discovered in their scores in rubbish bins, should rouse our consciences, and I should like to hear from the Minister when we last raised this issue with the Government of India.
Another country that stands out and, because of Ebola, is much on our minds is Sierra Leone. It is estimated to have the highest ratio of maternal deaths, with 1,100 per 100,000 live births. This estimate was made in 2013 and the situation then was bad enough, but obviously, with the inevitable decline in the infrastructure in Sierra Leone today, the situation is getting worse. I hope that the Minister will be able to say something about that.
Are we involved in the formulation of new development goals to ensure continued global advocacy and to ensure that action is under way? A proposed new goal is universal health coverage. Surely a universal gold standard, strengthening health systems worldwide and ensuring that care for mothers and babies is available, accessible and affordable, is one that the United Kingdom should be championing.
As we look at best and worst practice, do we ask what was done well, what was not done well, how care can be improved in the future and how much involvement there is of users and providers? Are we working to see the better development of perinatal audit and cause classification for maternal deaths, and the introduction of an urgently needed system to identify the cause of, and contributing factors to, stillbirth? I hope that my noble friend’s initiative today will help us to achieve some of those life-saving objectives. I am indebted to her for giving us the opportunity to contribute to this debate.
Lord Collins of Highbury (Lab)
My Lords, I, too, thank the noble Baroness, Lady Hayman, for initiating this important debate.
As we have heard, the UN estimates that over the past two decades the under-five mortality rate has almost halved; and the number of deaths of children under five is being reduced faster than at any time in the past two decades, partly due to increased access to vaccination against deadly childhood diseases. As we have heard, the number of women dying in pregnancy and childbirth has also been cut by almost half in the same period.
However, as we heard from the noble Baroness, Lady Hayman, this progress has not been even because women, adolescents and children from poor and marginalised communities are being left behind. Noble Lords have referred to the fact that nearly 800 women die every day in pregnancy and childbirth, and HIV/AIDS remains the leading cause of death for women aged between 15 and 44.
With little control over their lives, millions of adolescent girls are forced into early marriage, putting them at risk of complications from pregnancy and HIV at a young age. Faced with an unintended pregnancy, many women and girls resort to unsafe abortion, which accounts for 13% of all maternal deaths; and for every woman who dies, 20 others suffer illness, injury or disability.
As we have heard, mothers and babies face the greatest risks in sub-Saharan Africa, which accounts for 62% of all maternal deaths, followed by south Asia, with 24%. As the noble Lord, Lord Patel, said, two countries account for one-third of all maternal deaths: India, with 17%, and Nigeria, with 14%. It is worth repeating these statistics, because those are countries that we now consider middle-income countries, which do not need development support. But inequality there is growing rather than diminishing.
The noble Baroness, Lady Hayman, highlighted the maternal mortality ratio, showing the highest discrepancy of all health indicators—the gap between high and low-income settings. Sierra Leone has been mentioned: it is estimated to have the highest MMR, at 1,100 per 100,000 live births—and as we have heard, this estimate is from 2013, before the Ebola epidemic. There is emerging evidence that as a result of the Ebola epidemic more maternal deaths are occurring, both as a result of the virus and as a result of lack of availability of routine care, with the focus on care for patients with Ebola and the collapse of existing health systems—which were, as we have heard, incredibly weak already. I do not know how many noble Lords heard the BBC’s excellent report yesterday highlighting the additional risks to healthcare workers treating pregnant women with Ebola. It was a shocking story.
We have heard about millennium development goal 5a, to reduce maternal mortality by 75% between 1990 and 2015: 11 countries are “on track” to meet it, 63 countries are “making progress”, and 13 are “not on track”. Factors associated with making progress include leadership, working in partnership, using evidence, and being innovative and able to adapt using both long and short-term strategies.
Maternal and newborn health are closely linked. As we have heard, motherless children are up to 10 times more likely to die within two years of their mother’s death. More than 6 million children under five died last year, primarily from complications of prematurity and birth, pneumonia, malaria and diarrhoea, with under-nutrition a major factor. The survival rate of the most vulnerable children—newborns—is improving too slowly: 44% of deaths under the age of five occur in the first month.
As we have heard, nearly all maternal, child and newborn deaths are preventable. Strong health systems, with sufficient skilled health workers and reliable supplies of affordable essential commodities, medicines and vaccines, providing equitable access to universal health care, are critical. Proven strategies to improve maternal and newborn health include increasing access to quality care in pregnancy and childbirth, including emergency obstetric and newborn care, reproductive healthcare and information, family planning services and, most importantly, safe abortion.
Poor nutrition is an underlying factor in almost half of all child deaths under the age of five. The UK Government are a leader in the fight against hunger and under-nutrition, but can the Minister assure the House that all bilateral maternal and child health programmes include a strong nutrition component? The next Labour Government will put universal health coverage at the heart of the global development agenda. Universal health coverage affirms the right of every person to have the opportunity for the highest standard of health, without suffering financial hardship or poverty as a result. It does not just help improve health outcomes, but would help reduce inequality and stop 100 million people a year falling into poverty. Health and economic development are interdependent. Healthy populations are more productive.
It is clear from this and other recent debates in this Chamber that universal healthcare will make countries more resilient to humanitarian disasters and outbreaks of disease. The ability of Nigeria, which has a relatively strong healthcare system, to contain and beat the Ebola virus this year sharply contrasts with the experience of Sierra Leone and Liberia, whose health systems were weak. Universal healthcare is a clear and quantifiable goal. Will the Minister commit the Government to it in considering the language of the health goal in the SDGs when negotiations start in New York next week? What is her department doing to ensure that the next development framework is ambitious and trans- formational to end all preventable, maternal, child and newborn deaths?
As we have heard from my noble friend Lady Kinnock, addressing the underlying causes of ill health and mortality is also critical. As we heard from the right reverend Prelate the Bishop of Derby, this means investing in women’s empowerment, girls’ education, preventing gender-based violence and ensuring access to clean water and sanitation. Will the Minister highlight what the UK Government are planning and doing to address these underlying causes?
The Parliamentary Under-Secretary of State, Department for International Development (Baroness Northover) (LD)
My Lords, like other noble Lords, I pay tribute to the noble Baroness, Lady Hayman, for securing today’s debate, and for her long-standing commitment to maternal and neonatal health. I commend the other contributions we have heard today, which, as ever in your Lordships’ House, have ranged very widely. I also thank noble Lords for their tributes to DfID for our work. We have heard the devastating figures, and as my noble friend Lady Hodgson pointed out, a human face was given to those figures.
The noble Baroness, Lady Hayman, my noble friend Lady Hodgson, the noble Baroness, Lady Kinnock, the right reverend Prelate, the noble Baroness, Lady Tonge and now the noble Lord, Lord Collins, have all pointed out that this relates fundamentally to the rights of women and their unequal status, unequal access to nutrition and education and being forced into early marriage—we have heard the range of challenges. Gender inequality is key.
This is a very timely debate, coming right at the start of 2015, the final year of the millennium development goals and the year in which new goals will be agreed at the UN in September. Globally, as the noble Baronesses, Lady Hayman and Lady Tonge, said, we have made significant progress in reducing maternal mortality. The maternal mortality ratio dropped by 45% between 1990 and 2013. Each region of the world has seen significant improvement, though none, as noble Lords pointed out, has yet reached the goal of a 75% reduction in mortality.
These improvements have been driven largely by more women having access to skilled birth attendants—nearly 70% of births now take place with a skilled attendant. I note what the noble Baroness, Lady Tonge, and the noble Lord, Lord Alton, said about the high level of maternal morbidity. I pay tribute to the All-Party Parliamentary Group on Population, Development and Reproductive Health for its outstanding report, Better off Dead?, as well as to the work on fistula by the noble Lord, Lord Patel. It is not just a matter of physical morbidity. As my noble friend Lady Hodgson pointed out, the mental health of mothers is key. I hope that my noble friend will be pleased to note that mental health is included in the targets for the SDGs proposed by the open working group.
The noble Baroness, Lady Hayman, noted the number of neonatal deaths and that it had not moved in the direction that maternal mortality had. The MDGs did not include targets for newborns; consequently, they received less attention and less progress has been made. The noble Lord, Lord Patel, in particular emphasised how much more we still need to do. Nearly 3 million newborns still die every year, accounting for around 44% of all deaths of children under five, and 1 million of these die on their first day of life, as noble Lords noted. Eighty-five per cent of newborn deaths result from three preventable causes, as the noble Lord, Lord Patel, and other noble Lords pointed out.
The noble Lord, Lord Patel, emphasised the high incidence of neonatal deaths in a few countries, identifying particularly large numbers in the populous countries of India and Nigeria—the noble Lords, Lord Collins and Lord Alton, made reference to that as well. As the noble Lord, Lord Patel, noted, it is shocking to see the proportion of babies not breastfed in the first 24 hours. I was shocked when I visited India early last year to discover that this was indeed widespread. I can assure the noble Lords, Lord Patel and Lord Alton, that prioritising women and girls and seeking to address neonatal health is uppermost in our discussions in India. My right honourable friend Lynne Featherstone has been to India this week as a champion to combat violence against women and girls, so it is very high in the Government’s priorities.
As noble Lords made clear, faster progress in these crucial areas will be achieved only when girls and women are able to access the care and services that they need when they need them. They include better nutrition, access to education and access to clean water and sanitation. The United Kingdom has a strong track record of working to improve maternal and newborn health—and I thank noble Lords again for their tributes. In 2010, we made commitments to save 50,000 maternal lives and 250,000 newborn lives by the end of 2015, and we intend to meet them. We have already exceeded our target for maternal lives saved through a combination of increased investments in family planning, skilled birth attendants and making health systems stronger—all issues that noble Lords addressed. A number of noble Lords emphasised family planning, and we share their view that this is crucial, which is why we emphasised it at the London summit in 2012. A recent report shows that we are broadly on track to meet our commitments. Nevertheless, we are not complacent; we know how extremely important that issue is.
I agree with the noble Baroness, Lady Kinnock, that we need to make sure that we have adequate funding for sexual and reproductive health and that that includes funding from the country Governments themselves. The summit was encouraging, and I hope that the noble Baroness was able to see the commitments that came forward. We need to make sure that those are delivered. We agree that it is vital that girls and women should be able to access comprehensive packages of sexual and reproductive health.
Ensuring that the post-2015 development agenda continues to advance the social, economic and political empowerment and human rights of girls and women remains a top priority for the United Kingdom, and we will continue to work tirelessly to ensure that the final framework advances the needs of girls and women. The noble Baroness, Lady Kinnock, mentioned prioritising what women want in terms of safe abortion. Where girls and women have taken the decision to terminate a pregnancy, our aim is to ensure that they do not put their own lives at risk. Improving access to safe abortion saves maternal lives and reduces maternal ill health; I stress that very strongly.
Beyond international targets, we know what is needed on the ground. We need to see high-quality reproductive midwifery and emergency obstetric services being delivered through well functioning health systems. There is much more that we need to do. Most of these deaths are preventable. We must ensure that clear targets for improved sexual and reproductive health and rights are included to prevent maternal and newborn deaths. They must be secured in a post-2015 framework. We are working extremely hard on this and anything that noble Lords can do working with southern voices in these next crucial months is vital.
My noble friend Lady Tonge mentioned the omission of “sexual rights” from the UN Secretary-General’s recent synthesis report. This report is one of many inputs into the process. We still wish to see the full sexual and reproductive health and rights package reflected in the final framework. We need to ensure that women can access contraceptives if they wish to prevent pregnancy and, if they become pregnant, have access to skilled health workers who have the right drugs and equipment at the right time in the right place to be able to respond to complications during pregnancy and childbirth. I was very moved at the Christian Aid carol service to hear some of the stories from Kenya.
We need health financing systems that mean women do not have to make choices between accessing care and feeding their families. I agree with the right reverend Prelate in terms of finance that a sustainable solution can come only when countries finance their own healthcare adequately. He is absolutely right that tax reform is a key part of that.
We need supporting information systems that tell us whether our efforts are working and how and where to improve them, ideally taking advantage of new technologies, as the noble Lords, Lord Alton, Lord Collins and others mentioned. All this is why universal health coverage must be an important part of the post-2015 agenda. Strong health systems are vital. It is because Sierra Leone and Liberia have fragile health systems as fragile countries that the Ebola epidemic was able to take hold. That is why we are involved in such countries and why such health strengthening has received 20% of DfID’s budget.
We need to continue to work on the social determinants of health, such as poverty, better nutrition, education, and so forth, as I have said. Crucially, as noble Lords have made clear, we need the empowerment of girls and women, to enable them to have voice, choice and control within their households, their wider communities and across their nations. Noble Lords have made a powerful case for that. That means working at every level. I agree with the right reverend Prelate that that clearly involves working at community level and we have our aid-matching system as one of the key mechanisms for that. There are others in our portfolio of support for civil society.
All this is doubly important when we are talking, as noble Lords have, of the hardest-to-reach groups: the youngest, the poorest, the most geographically isolated and those affected by conflict—those left behind by the progress towards the current MDGs. That is why the new set needs to ensure that they leave no one behind. More rapidly declining rates of maternal and newborn deaths will tell us when we are getting this right.