Allan Rosenfield

MATERNAL MORTALITY-A NEGLECTED TRAGEDY: Where is the M in MCH?

Despite increasing attention to maternal and child health programs most do little to reduce maternal mortality. In developing countries maternal death rates of 100-300/100000 births are common; rates are even higher in rural areas. Only 1 of the components of most maternal-child health programs (oral rehydration growth monitoring breastfeeding family planning and immunization) can reduce maternal mortality--family planning. Women who have many births or give birth at either extreme of the reproductive cycle are more likely to die of complications than other women. If all women who want to limit their families had access to efficient contraception matenal mortality would be substantially reduced. Also needed is a major investment in a system of comprehensive maternity care. 75% of obstetric deaths are due to hemorrhage infection toxemia and obstructed labor. Many of these complications occur among women with recognizable risk factors. It is recommended that the World Bank make maternity care 1 of its priorities. The Bank could initiate a program based on the construction of maternity centers in rural areas the recruitment and training of staff for these centers and the provision of supplies and drugs. Because women receiving maternity care can be offered family planning services as well this proposal provides the World Bank with an opportunity to work toward its goal of reduced population growth rates.

Transforming health systems to improve the lives of women and children

Ambitious quantitative goals for reducing mortality and increasing access to health interventions are nothing new to the areas of child maternal and reproductive health. They are the standard fare of global declarations and national 5-year plans. They come. They go. What makes the Millennium Development Goals (MDGs) different? With health firmly embedded in this wider poverty-reduction initiative which has garnered unprecedented consensus and support from governments and multilateral organisations the global health community has a rare opportunity to break through to new ways of thinking about the obstacles now blocking improvements in the health of women and children and to translate that thinking into bold new steps to meet goals 4 and 5 (table). For the UN Millennium Project Task Force on Child Health and Maternal Health the potential breakthrough lies in putting health systems at the centre of MDG strategies and in addressing these systems not only as delivery mechanisms for technical interventions but also as core social institutions—as part of the very fabric of social and civic life. In high-mortality countries today especially for the poorest populations health systems are frequently the source of catastrophic costs humiliating treatment and deepening social exclusion. But a different way is possible. Health systems can be a vehicle for fulfilling rights for active citizenship and for true democratic development—poverty reduction in its fullest sense. (excerpt)

Focus on Women: Linking HIV Care and Treatment with Reproductive Health Services in the MTCT-Plus Initiative

Abstract Despite important advances in expanding access to antiretroviral therapy in the countries most heavily affected by HIV/AIDS, there has been little consideration of the connections between HIV prevention, care and treatment programmes and reproductive health services. In this paper, we explore the integration of reproductive health services into HIV care and treatment programmes. We review the design and progress of the MTCT-Plus Initiative, which provides HIV care and treatment services to HIV positive women as well as their HIV positive children and partners. By emphasising the long-term follow-up of families and the provision of comprehensive care across the spectrum of HIV disease, MTCT-Plus highlights the potential synergies in linking reproductive health services to HIV care and treatment programmes. While HIV care and treatment programmes in resource-limited settings may not be able to integrate all reproductive health services into a single service delivery model, there is a clear need to include basic reproductive health services, such as access to appropriate contraception and counselling and management of unplanned pregnancies. The integration of these services would be facilitated by greater insight into the reproductive choices of HIV positive women and men, and into how health care providers influence access to reproductive health services of people with HIV and AIDS. Résumé Malgré une amélioration de laccès à la thérapie antirétrovirale dans les pays les plus touchés par le VIH/SIDA, les liens entre les programmes de prévention, soins et traitement du VIH et les services de santé génésique nont guère été étudiés. Dans cet article, nous examinons lintégration des services de santé génésique dans les programmes de soins et traitement du VIH. Nous analysons la conception et les progrès de lInitiative PTME-Plus, qui assure des services de soins et traitement aux femmes séropositives ainsi quà leurs enfants et partenaires infectés. En privilégiant le suivi familial à long terme et les soins complets à tous les stades de linfection, PTME-Plus souligne les synergies déclenchées en liant les services de santé génésique avec les programmes de soins et traitement du VIH. Si dans les environnements à ressources limitées, ces programmes ne peuvent pas toujours intégrer tous les services de santé génésique en un modèle unique de services, il faut néanmoins y inclure des services de santé génésique de base, comme laccès à une contraception adaptée et des consultations, et la gestion des grossesses non désirées. Lintégration de ces services serait facilitée par une meilleure connaissance des choix génésiques offerts aux femmes et aux hommes séropositifs, et de linfluence des prestataires de soins de santé sur laccès des séropositifs aux services de santé génésique. Resumen Pese a los importantes avances en la ampliación del acceso a la terapia antirretroviral en los países más afectados por el VIH/SIDA, no se ha pensado mucho en las conexiones entre los programas de prevención, atención y tratamiento del VIH, y los servicios de salud reproductiva. En este artículo, exploramos la integración de estos ãltimos a los programas de atención y tratamiento del VIH. Revisamos el diseño y los avances de la Iniciativa MTCT-Plus, que proporciona servicios de atención y tratamiento del VIH a las mujeres VIH-positivas, sus hijos y sus parejas VIH-positivos. Al dar énfasis al seguimiento de las familias a largo plazo y a la provisión de atención integral en todo el espectro de la enfermedad del VIH, la MTCT-Plus destaca las posibles sinergias en vincular los servicios de salud reproductiva a los programas de atención y tratamiento del VIH. Aunque es posible que, en ámbitos con pocos recursos, estos programas no logren integrar todos los servicios de salud reproductiva a un solo modelo de prestación de servicios, indudablemente es necesario incluir los servicios esenciales de salud reproductiva, como el acceso a anticonceptivos y consejería apropiada y el manejo de embarazos no planeados. La integración de estos servicios se facilitaría al tener más conocimiento sobre las decisiones reproductivas de las mujeres y los hombres VIH-positivos, y sobre cómo los profesionales de la salud influyen en el acceso de las personas con VIH/SIDA a los servicios de salud reproductiva.

Sexual and reproductive health for all: a call for action

At the United Nations International Conference on Population and Development in Cairo in 1994, the international community agreed to make reproductive health care universally available no later than 2015. After a 5-year review of progress towards implementation of the Cairo programme of action, that commitment was extended to include sexual, as well as reproductive, health and rights. Although progress has been made towards this commitment, it has fallen a long way short of the original goal. We argue that sexual and reproductive health for all is an achievable goal--if cost-effective interventions are properly scaled up; political commitment is revitalised; and financial resources are mobilised, rationally allocated, and more effectively used. National action will need to be backed up by international action. Sustained effort is needed by governments in developing countries and in the donor community, by inter-governmental organisations, non-governmental organisations, civil society groups, the womens health movement, philanthropic foundations, the private for-profit sector, the health profession, and the research community.

Meeting MDG-5: an impossible dream?

Reduction of the maternal mortality ratio by three-quarters by 2015 is the target for one of the eight Millennium Development Goals (MDGs) set by 189 countries in 2000. That this goal (MDG-5) is the one towards which the least progress has been made despite the launch nearly 20 years ago of the Safe Motherhood Initiative is widely acknowledged. Nonetheless we believe that substantial progress can be achieved. Indeed a 2003 World Bank report on the success of several developing countries in (including China Sri Lanka and Malaysia) reducing maternal mortality rates concluded that maternal mortality can be halved in developing countries every 7--10 years…regardless of income level and growth rate. To make real progress by 2015 substantial flexible medium-term funding for field programmes and related research is needed with a clear focus on important programme elements implemented with commitment to the crucial goal of strengthening national health systems. (excerpt)

Abortion and fertility regulation

Abstract To achieve their desired fertility, women use a combination of contraception and abortion, and some societies also place constraints on marriage and sexual activity. The degree to which these means are adopted varies considerably, but for the foreseeable future abortion will remain an important element of fertility regulation. Globally, complications of unsafe abortion affect hundreds of thousands of women each year, and account for as many as 100 000 deaths annually (about two in ten maternal deaths), mainly in poor countries, where abortion typically remains illegal. Access to safe abortion is both essential and technically feasible and should be provided in combination with good quality family planning services.

The pricing and procurement of antiretroviral drugs: an observational study of data from the Global Fund

The Purchase price report released in August 2004 by the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) was the first publication of a significant amount of real transaction purchase data for antiretrovirals (ARVs). We did an observational study of the ARV transaction data in the Purchase price report to examine the procurement behaviour of principal recipients of Global Fund grants in developing countries. We found that, with a few exceptions for specific products (e.g. lamivudine) and regions (e.g. eastern Europe), prices in low-income countries were broadly consistent or lower than the lowest differential prices quoted by the research and development sector of the pharmaceutical industry. In lower middle-income countries, prices were more varied and in several instances (lopinavir/ritonavir, didanosine, and zidovudine/lamivudine) were very high compared with the per capita income of the country. In all low- and lower middle-income countries, ARV prices were still significantly high given limited local purchasing power and economic strength, thus reaffirming the need for donor support to achieve rapid scale-up of antiretroviral therapy. However, the price of ARVs will have to decrease to render scale-up financially sustainable for donors and eventually for governments themselves. An important first step in reducing prices will be to make available in the public domain as much ARV transaction data as possible to provide a factual basis for discussions on pricing. The price of ARVs has considerable implications for the sustainability of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) treatment in the developing world.

The AMDD program: history, focus and structure

The AMDD (Averting Maternal Death and Disability) Program was established at the Mailman School of Public Health in 1999. In this article, we discuss four key aspects of the program: the focus on emergency obstetric care; the use of process indicators; working with partners; and applying human rights.

Abortion and maternal health.

Since the beginning of recorded history, women have attempted to terminate unwanted pregnancies. Despite the safety of modern techniques of abortion, many women throughout the world still have to resort to unsafe abortions, placing themselves at considerable risk. The World Health Organization estimates that there are approximately 20 million unsafe abortions performed each year, and estimates of maternal deaths as a result of abortion range between 60u2008000 and 100u2008000 per year. With free and legal access to safe abortions, rates of complications and mortality drop dramatically. There is an urgent need for efforts to prevent unwanted pregnancies in order to reduce the need for abortion; for the early identification of abortion complications and easy access to treatment for women suffering those complications; for expansion of safe abortion availability; and for proper training and resources for providers of abortion services.

Maternal mortality: community-based interventions.

Maternal mortality is one of the great neglected problems of health care in developing countries. The World Health Organization estimates that approximately 500 000 women die each year from pregnancy‐related causes, over 98% of these deaths occurring in the developing world, where maternal mortality is as much as 100 times higher than rates seen in industrialized countries. The most common causes include obstructed labor and ruptured uterus, postpartum hemorrhage, eclampsia, postpartum infection and complications of illegal abortion. It is suggested that no new or costly technologies are needed; rather that appropriate priority setting and allocation of needed resources are essential to the solution of the problem. There are few interventions that hold much hope of success at the village level, although antibiotics, ergotrate, and sedatives might be productively utilized, after appropriate training. Overall, however, networks of maternity care facilities, trained personnel, and means of transport are necessary to provide needed emergency maternity care services.