Maternal Health: A Priority to Ensure the Health and Rights of Women
¿Quousque tandem abutere, Catilina, patientia nostra? Or, in English: How long, o Catiline, will you abuse our patience?
Any chance any of you have studied Latin? I have. My parents insisted that Latin would be useful to me throughout life. Maybe they were right, but this is the first time I have used it. It has, however, allowed me to bring back this very old speech by Cicero to talk about a very contemporary issue: maternal mortality.
The scourge of maternal mortality is not new. What is new is the impatience many of us feel at the lack of concrete solutions to a problem that has existed for so long. Impatience because women continue to die, despite the fact that low-cost, simple solutions exist. Impatience because these deaths are preventable, and, for that reason, immoral.
But let's start with the good news. The latest figures, published last week by the United Nations, show a marked decrease in maternal mortality rates worldwide. In the past two decades, maternal mortality has fallen by 47%. This is an impressive achievement. It is only fair to recognize and celebrate it. But it is also fair to keep a critical eye. These advances are not enough. Greater efforts are needed. We need to reduce maternal mortality rates by 75% by 2015, as set out in the Millennium Development Goals.
In Latin America and the Caribbean, the maternal mortality rate is relatively low when compared with other regions. Our region has a rate of 80 deaths per 100,000 live births, well below that recorded in sub-Saharan Africa and South Asia.
This is objectively true, but misleading: If I break down the region’s maternal mortality rate by country, I can easily demonstrate that the regional average hides large differences. In many parts of Latin America, maternal mortality rates are extremely high, approaching the levels found in Sub-Saharan Africa. I’ll just mention the cases of Haiti and Guyana, where the rates are 350 and 280 deaths per 100,000 live births, respectively.
We could also look at the huge differences by income quintiles, an embarrassment in a region that prides itself on the progress made in recent decades towards democratization. But this is something we all know too well. And, to be frank, I don’t believe it’s very useful to join the continuous fight to prove what region has the worst figures in order to get a bigger share of international aid for development. This sort of competition for the trophy of misery has no use to anyone. What is useful and what I want to strongly emphasize is that every single death counts and, every woman counts.
For a region like ours, which has experienced remarkable economic growth over the last decade and whose countries are now considered as middle income, our maternal mortality rate is simply outrageous. Rates of maternal mortality in developed countries are five times smaller. And as if this were not enough, our region registers the least progress in reducing maternal mortality. In Latin America each year nine thousand women die from complications related to pregnancy. Most of these deaths occur among poor women. We have to change this unjust reality!
So why does maternal mortality persist in our region? From my perspective, the reasons can be grouped into four broad categories :
1) Our high levels of inequality.
2) Our tendency to try to hide from reality by avoiding the problem of unsafe abortion.
3) The low priority we give to young and poor women.
4) The limited resources we devote to a problem so serious and so easy to solve.
I would like to talk briefly about each of these points. Let’s start with the issue of inequality . As you well know, our region has the sad honor of being the most unequal in the world. Although in terms of income per capita we are richer than other regions, in terms of inequality we are in last place, even behind Africa.
Income differences between rich and poor are scandalous. A recent report by the Economic Commission for Latin America and the Caribbean (ECLAC) notes that in our region, the income received by the four poorest deciles is, on average, less than 15% of total income while the richest decile receives about a third of total income.
The income inequality manifests itself in all spheres of life. Health is a clear example. The Inter-American Development Bank shows a strong correlation between inequality in income distribution and inequality in access to health services. Sexual and reproductive health does not escape this reality.
Allow me to show you a graph illustrating inequalities in care during birth between the wealthiest and poorest . We see that in all these countries inequalities are very strong. Women in the highest income quintile have more access to services provided by skilled personnel than the lowest income quintile. The same is observed when we analyze the use of contraceptive methods. Again, the differences between the poorest quintile and the richest are enormous. These inequalities generate serious consequences, especially for the poorest women.
We must be impatient with inequalities. They can be reduced through social and economic policies. Brazil, the world champion of inequality is already changing. Let us join those who are proposing to include the reduction of social gaps in the next Millennium Development Goals. Let us be very impatient!
Unsafe abortion is another factor that strongly contributes to the persistence of maternal mortality. In our region, where priests have excommunicated a mother seeking an abortion for her 12 year-old daughter after she was impregnated by her stepfather, approximately 4.2 million abortions are performed every year. The problem is that 93% of these abortions are unsafe. The incidence of unsafe abortion in our region is the highest in the world.
These alarming figures are largely the result of a highly restrictive legal framework. Of the five countries in the world where abortion is completely banned, four are in our region. And the majority of other countries have very specific causes that restrict access to safe abortion.
Each year, more than a million women in our region are hospitalized from complications caused by unsafe abortion. And one in eight maternal deaths is caused by unsafe abortion.
The inequality I mentioned earlier means poor women suffer the most from unsafe abortions as they cannot afford trained professionals. The criminalization of abortion is completely ineffective. In fact, a recent Lancet study shows that abortion rates are higher and are increasing in the countries where it is prohibited, while they are declining in the countries where abortion is legally permitted.
But it is important to reiterate that abortion is not the problem. The problem is illegal and underground abortions. When performed by trained professionals under appropriate conditions, and in accordance with World Health Organization standards, abortion is extremely safe, yielding a mortality rate of 0.6 per 100,000 procedures. Here in Mexico City, after it was legalized, deaths resulting from abortion became nearly extinct.
And unsafe abortion is not only a matter of public health and human rights; it is also an economic and social problem. Treatment of complications resulting from unsafe abortion represents an unnecessary burden on public health systems and consumes a lot of vital resources. Moreover, as different studies show, complications resulting from unsafe abortion reduce the productivity of women and make them more vulnerable to poverty.
Fortunately, thanks largely to the activism of civil society organizations and the women's movement, we’ve seen encouraging developments in recent years. Colombia and Mexico have made significant progress in the decriminalization of abortion. Brazil has recently increased the grounds for cases of anencephaly. We also had big wins in litigation cases in national and international courts. These victories are remarkable and should be celebrated.
I am convinced that the decriminalization of abortion in the region is only a matter of time. The efforts we’ve put towards this cause for decades are beginning to bear fruit. Setbacks are bad but not definitive. History and reason are on our side.
But the fight does not end with changing the legality of abortion. We need to ensure that changes made on paper are actualized to make a real and effective impact. Changes in the legal framework should be widely publicized and explained to the population and medical professionals to ensure effective implementation as ignorance on this subject is often widespread. We must also support the development of clear medical protocols that allow for the effective application of laws and are widely disseminated.
Civil society and the women's movement will be key to making this happen. But it is important not to isolate ourselves. This has to be a coordinated effort, and strategic alliances with other groups—such as media, professional associations, legislators and the ministries of health—must be made. In Mexico City, for example, decriminalization was the result of excellent work carried out by a coalition of lawyers and public health organizations led by the women's movement who worked to build will among the public and opinion leaders. There is much to learn from what has been done in Mexico City.
We must be impatient. During the Cairo + 20 talks we must take the issue of abortion beyond what was achieved in Cairo. We must be very eager to end the needless deaths of poor women.
And so we reach the third issue that I wanted to touch, the health of young women. I speak particularly about access to contraception. According to the United Nations, preventing unwanted pregnancies alone could prevent about one quarter of total maternal deaths, including those caused by illegal abortions.
As we know, one way to mitigate unwanted pregnancies and unsafe abortions is ensuring access to contraception. However, despite the progress made and the intervention of national governments in this field in recent years, there are still many women, especially young women, who lack access to contraception in our region. In most of our countries, between 30% and 50% of sexually active unmarried women age 15 to 24 do not use any contraceptive method.
The rate of teen pregnancy in Latin America and the Caribbean is one of the highest in the world, just below sub-Saharan Africa. In our region, 38% of women become pregnant before age 20 and almost 20% of births are to teenager mothers. Moreover, the number of adolescents between 15 and 19 who are mothers is growing in some countries. And as usually is the case, inequality is present in all these problems: pregnancy rates are three to five times higher among poor adolescents.
All women, including the young ones, need information and access to contraception to avoid unwanted pregnancies. They need information to make decisions about their sexuality and the number of children they’ll have and when. But young women face formidable social and psychological barriers. And these barriers are deeply rooted and originate in the denial of their sexual rights.
In most societies there is still a marked reluctance to acknowledge young people’s rights, and an equally strong denial to recognize them as sexual beings. This lack of recognition, coupled with the lack of adequate policies to ensure the exercise of these rights greatly hampers their access to comprehensive sexuality education. In this issue we are still in the Stone Age. Even today, many young people lack basic knowledge about transmission of HIV/AIDS.
Comprehensive sexuality education that goes beyond the facts of biology, and leads to the creation of egalitarian gender relations that are mutually respectful and pleasant, is a privilege that very few young people have.
However, I believe we arrived at a historical moment in which we’ll gain respect for the sexual rights of young people r and will turn sex education a reality in all schools. It is extremely important that we keep charging governments to fulfill the commitments made here in Mexico, in 2008, when they signed the Ministerial Declaration “Educating to Prevent,” and agreed to adopt national comprehensive sexuality education programs. The International Planned Parenthood Federation/Western Hemisphere has formed a coalition to monitor implementation of the declaration in Mesoamerica and has developed a tool to assess the progress made by each signatory country. As we can see in this chart, although progress has been made, much remains to be done.
We must be impatient. The Cairo + 20 talks provide an excellent opportunity for us to do for sex education what Cairo has done for reproductive rights. We started in a very good note with the Declaration adopted by the Commission on Population and Development in April in New York.
Before I close, I want to address a key obstacle for the goals I just described: the few resources we devote to these issues. We are yet to put our money where our mouth is. Even sectors of civil society that defend sexual and reproductive rights do not spend much time demanding the resources necessary for implementation of policies. Besides, the segmentation of our agendas diminishes our ability to have an impact. After all we’ve achieved nationally, regionally and globally, we, the defenders of reproductive rights, still segment our agendas between reproductive health, maternal health, HIV/AIDS and sexual rights, when all problems and solutions related to these issues are inherently integrated.
On the other hand, our governments have signed international commitments often without any follow-thru. At the same time, international donors lost interest in our region.
Latin America finds itself in the paradox of growth. Per capita income has increased since 2005 by 73%. However, 53 million people still live on less than $ 2 per day. The issue of poverty clearly remains unresolved.
Moreover, this strong economic growth has not been accompanied by a significant increase in investment in health: since 2005, per capita health spending has grown only by 18%, well below the increase in income per capita.
In addition, a third of all health spending comes directly from the pockets of users. Consumers in the region have more out-of-pocket health expenses than in any other place, spending more than double the amount paid by users in developed countries.
Unfortunately, international donors are confusing economic growth with social development. Latin America is no longer a priority for agencies and foundations that provide development assistance, largely because of the relative success we achieved in recent decades. It is assumed that the needs of our countries are on track to be met and that poverty is no longer a problem. Therefore, donors are directing their gaze almost exclusively to low-income countries.
This change of strategy is wrong. As demonstrated by a recent report, today most of the world’s poor live in middle income countries. The exit of international donor countries and the decision to stop funding organizations of civil society will eventually have a negative impact on health indicators.
There was a sharp cut in funding for our region in general and issues related to sexual and reproductive health were specially affected. In 2010, only 0.5% of official development aid to Latin America addressed the area of sexual and reproductive health. And in 2010, the funds allocated to this sector fell by 31% for government initiatives and by 20% for civil society organizations. Data for 2011 are not yet available, but it is only natural to anticipate the figures will be even worse as major donors such as Spain have slashed their budgets because of the economic crisis.
I repeat: the myopic single focus of donors on the most miserable countries in the world is wrong. We’ll all benefit if we recognize that many countries, including middle income ones, have a long way to go to guarantee the exercise of sexual and reproductive rights. We also need to recognize the importance of supporting civil society to help create the political will to allocate resources by national governments. At the same time, we must assure accountability in commitments made by these organizations.
I conclude where I started. We are still very impatient. We won’t accept preventable deaths any more. We want more resources. We want more action from governments and donors. We want more transparency. We want youth empowerment. We want comprehensive sexuality education. We want greater recognition of sexual rights and reproductive rights. We want to end unsafe abortion. And ultimately, we want a fairer world. It is in our hands, we just need to make it happen.