EDITORIAL: Safe Motherhood: The Road from Nairobi

Mahmoud F. Fathalla


In February 1987, the safe motherhood initiative was launched in Nairobi. In October 1997, an international technical consultation was convened in Colombo to review ten years of lessons and progress. The World Health Assembly selected the theme of Pregnancy is Special: “Let us make it Safe” for the 1998 World Health Day on April 7. It is time for all of us concerned about making motherhood safe to look back and to take stock for moving forward.

The road to Nairobi started when the world woke up to the reality of a major tragedy. This was no new epidemic; throughout the ages women have died from complications of pregnancy and childbirth. But it was not until this time that three factors converged to awaken us. The first factor was the accumulation of data from epidemiological research which showed that haifa million women were dying every year as a result of pregnancy and childbirth, and several millions more were suffering from severe morbidity.

The second factor was the realization that this suffering did not need to happen. Maternal mortality is largely avoidable, and in developed countries it has become something of the past. The third factor which was also very important was the increasing status of women. The lives of women came to mean more and it was considered that they were worth saving.

On the road to Nairobi, the concern was to make the case that motherhood should be made safe. The road from Nairobi to Colombo was not about the “should” but about the “could”. Can we make motherhood safe, and how can we do so?. It was not easy, but ten years along the road, we now know that motherhood can be made safe. We know about the interventions that can make a difference, and we have learned some hard lessons along the way.

We know that there are three categories of interventions which can have an impact on safe motherhood. In my classes, I use the letters A, B, C, D, E, and F to specify these interventions. The first category contains interventions that are needed by all women and that are justified on their own, irrespective of their impact on safe motherhood. These are Advancement of women and fiirth planning. The second category includes the interventions needed by all pregnant women, irrespective of whether they are liable to life-threatening complications. These are community- based prenatal care and elivery by a trained birth attendant. The third category consists of interventions that are needed by women experiencing a life-threatening complication. These are ,ssential obstetric care and Facilities for referral.

On the road after Nairobi, we also learned some hard lessons. They are hard lessons because they defy some conventional wisdom in one sense or another. The first piece of conventional wisdom

that does not apply is that prevention is better than cure. Unfortunately, life-threatening cornplicatioi s of pregnancy and childbirth are for the most part not preventable. In fact, we can only prevent two of the major causes: one is unsafe abortion, and the other is puerperal sepsis.

Another piece of conventional wisdom is the risk approach, a good public health approach for the rational allocation of resources: we identify from the outset the people who are at risk, and then target interventions and resources to these people. Unfortunately, most of the complications of pregnancy and childbirth are not predictable.

It is also conventional wisdom that primary health care is the right approach to achieve health care for all, by an equitable allocation of resources and by emphasizing the low-cost interventions that will benefit the majority rather than the high- cost interventions directed to the few. For those of us who have put our faith in primary health care, it has taken some time to realize that, as far as safe motherhood is concerned, primary health care alone is not enough. We can detect complications of pregnancy and childbirth at the primary health care level, but their management will need to be done at a higher level.

Another conventional wisdom is that development is the solution and that poverty is at the root of all health problems in the third world. This is correct, but where safe motherhood is concerned it needs a qualification. A well-off woman in the city is as likely to develop a placenta previa and serious anteparturn haemorrhage as a poor woman in a village. The only difference is the access to quality health care. The important lesson here is that pregnancy and childbirth are a risky business. Every woman is at risk and every woman should have access to the appropriate health care if the need arises.

If the road to Nairobi was about the “should’ and the road from Nairobi to Colombo was about the “could’ the road ahead is about the “will” backed by the “wallet”. Maternal mortality is still a major neglected tragedy. In Africa alone, WHO and UNICEF estimate that 235,000 women die each year in Africa in the process of pregnancy and childbirth. In ten African countries and two countries in Asia, the lifetime risk of maternal death for a woman is less than one in ten. A basic requirement to sustain the will for safe motherhood is to raise the level of the issue from being a simple health matter to being a human rights issue. Maternity is not a disease. Maternity is a privilege. Women are entrusted with the survival and propagation of our species. Women have a basic right to be protected when they risk their health or life in the process of giving us life. Women’s right to safe motherhood should be high on the agenda of women’s movements everywhere. It is true that women in the North have probably forgotten what a maternal death is; but for their sisters in the South, the journey of pregnancy and childbirth is still a dangerous one from which many do not return. Women’s right to life is an issue around which all women should mobilize and act.

The will to make motherhood safe must be backed by the wallet. Safe motherhood is affordable. Resources can be mobilized, and cost-effective interventions are available. The question that societies must answer is how much is the life of a mother worth.

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