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Introduction: The world is on the way of attempting fulfilling the millennium development goals. Maternal health and women development both are very important goals of MDG which are closely related with each other. Without ensuring good health of women, it is difficult to ensure women empowerment and development. Poor health women cannot actively participate in the socio-economic development process. Women with good health can be a better mother, better mother produce healthy children, healthy women also confirm better labors or employees, better employees makes rich economies, and rich economies that allow people to live freely and having better choices. Perceiving this, world policy makers bring women development and maternal health issues in the millennium development goals. As a citizen of an economic underdeveloped country, Bangladesh, I have witnessed how women have highly suffered from these issues. I also realize that the whole of the MDGs will highly hamper if the above mentioned goals remain incomplete. So, in the current paper, I try to show how the maternal health is closely linked with women development.
The General Assembly of the United Nations adopted the Millennium Development Goals (MDGs) on September 18, 2000, at the UN Millennium Summit. Signed by nearly 190 countries, MDGs usually refer to 8 goals to be achieved by 2015, which are ultimately linked to 18 targets & 48 indicators. Such an unified group of goals agreed by 190 countries to meet is completely unprecedented. The MDGs arose from the wishes to turn the millennium good intentions into actions. Under 'values & principles', the UN General Assembly agreed that, the challenges undertaken are to realize the benefits of globalization, to ensure the equal distribution of costs & benefits across nations on the basis of humanity in all aspects of life (UN, 1999). They also hoped that the realization of the goals will provide us a shared future. They also committed to make billion of men, women & children free from the curse of poverty & to ensure everyone's right to development (Desai and Potter, 2008: 30).
Cited on http://www.un.org/millennium/declatation/ares552e.pdf)
Is maternal health the pre condition of women development?
Is existing maternal health and women development achievement enough to fulfill the MDGs target?
Methodology: The researcher used data and information from only secondary sources. Requirement data and conceptual literature collected from course literature, published articles and various International Organizations web page. This paper focused on the definitions, relation between terms, theoretical basis, classification and types, operations, progresses and other issues relevant for the purpose of the study.
Women and Development:
Women play multiple roles at a time, such as: mother, leader, decision maker, student, farmer, worker & so on. And each role requires proper education and the existence of health, voice & influence of the women. Gender equality & women's empowerment are crucial to the achievement of MDGs. Lacking of these abilities women will be least able to serve the best of their potential, and be less productive.
Millennium development goals are inter-linked. Therefore, progress in one help to improve the condition of others. The effect of gender inequality is dangerous & a barrier to the development of a nation. The negative aspects of gender inequality include higher poverty among women than men, lower education, lack of autonomy, lack of mobility, etc. Thereby achieving gender equality will empower the women & accelerate the achievement of other goals. For example, gender equality in education increases the overall consciousness of people, which ultimately reduces malnutrition and child mortality. (UNIFEM, 2009 cited on http://www.unifem.org/attachments/products/annual_report_2008_2009_en.pdf)
Women and Development overview of MDGs aspect:
Most of the women's deaths in our society take place due reasons such as: their lack of family planning, less control over the number of children, from violence, and the lack of money to pay for transport and for skilled birth attendance or emergency obstetric care. It is assumed that, one-third of the maternal deaths related to pregnancy & childbirth can be avoided, if their access to effective contraception can be ensured. (CITATION needed) Therefore, women's empowerment is a prerequisite to move further in the MDGs.
Women themselves can ensure their sound health. Those who are engaged in different sectors of health can ensure the proper & timely delivery of health needs. They can ensure attention to local health care provision & can remove the inequalities in health outcomes & access existing in every region. In order to reduce the maternal mortality rate there has to be an eradication of all kinds of violence against women, such as: child marriage, female genital mutilation, dietary restrictions etc.
All over the world, in most of the societies, women deal with the cooking of the household. And most of the households use wood, crop residues; to cook which exposes them to indoor air pollution & cause acute diseases such as: lung cancer & respiratory infections. Uses of cleaner alternatives such as: gas, electricity, solar energy etc. can reduce keep women free from such fatal disease & reduce mortality of women & girls. (UNIFEM, 2009 cited on http://www.unifem.org/attachments/products/annual_report_2008_2009_en.pdf)
Indicators of Maternal Health: Most of the economically underdeveloped especially south Asian & sub-Saharan countries are posed by a high maternity death rate. Compared to 350 maternity deaths in per 100000 live births of other low & middle income countries, there were 540 deaths in India in 2003. And the overall scenario reflects 72 deaths per 1000 births (who?) Therefore, maternal mortality is the most visible indicator of the poor health of women.
The reliability of maternal & child health depends on a variety of social, biological & environmental factors such as: adequate food & nutrition, clean water & good sanitation, sufficient health care services etc. (Millennium Development Goals Report 2010, Goal 5, United Nations)
Causes of Maternal Mortality:
Direct Causes: There are several causes of maternity death, where some causes are direct & some others indirect. Among the direct causes, hemorrhage & hypertension account for about half of the death of expecting mothers. There are some other direct causes such as: obstruct red labor, complications of anesthesia & caesarean etc. This problem in maternity stage causes 11 % of the total maternal deaths. In this case, Malaria, HIV/AIDS, & heart diseases are encountered as indirect causes of maternity deaths & consist of 18% of the total deaths.
It is a matter of hope that a major portion of these deaths are avoidable. For example, hemorrhage can be prevented by the proper administration of a skilled health care practitioner & with adequate equipment & supplies.
It is also hopeful that the rate of people receiving skilled healthcare assistance during the pregnancy period is increasing day by day. When only 53% of the women were getting practitioner's assistance in 1990, it grew to 63% in 2008. The improvement was all over the world, but amazing in Northern Africa & South-Eastern Asia. The percentage was 74% & 63% respectively. But unfortunately, the sub-Saharan Africa didn't progress as par; less than half of the expecting mothers get attention of skilled practitioners. (Millennium Development Goals Report 2010, Goal: 5)
Poverty is the key determiner of maternal health and mortality: In 2000, "Improve Maternal Health" was adopted as the Goal-5 of MDGs, with two distinct targets: 1. To reduce maternal mortality ratio (MMR) three-quarters by 2015 & 2. To achieve universal access to reproductive health by 2015. But a decade afterwards only 2.5% MMR decline was observed, too little gain to achieve the target.
Most of the maternity deaths occur due complications at the period of pregnancy, at delivery or post delivery within 6 weeks. So they can be easily avoided just by timely availability of health care services. Different initiatives are necessary to ensure the availability of antenatal, delivery & postnatal services. But it is surprising that, most of the researches on maternal healthcare services focus on the first two, whereas the third one is neglected.
A Demographic & Health Survey (DHS) of 55 countries in the mid 1990s found, women in the richest quintile, 5.2 times more interested to give birth with the attendance of a doctor, nurse or midwife than women in the poorest quintile. Except Europe & Central Asia, in other poorest regions, less than 50% women get the opportunity to give birth with support from a medically trained person. On the other hand, 80% or more women in the highest wealth regions give birth in the attendance of trained personnel. On an average, just about 22% women in South Asia & less than half in sub-Saharan Africa give birth in the presence of trained & skilled practitioners. The above scenario exhibits that, the poorest women in the poorest regions of the world get the least access to maternal health care services. (change quoting.. ICRW or the author, then year and then pageâ€¦Targeting Poverty and Gender inequality to improve maternal health, Women Deliver, ICRW)
Cost is major impediment of Maternal Health Services:
All the formal & informal fees, the cost of drugs & equipment, cost of transportation to hospital or clinic as well as the opportunity cost of time are included in the cost of health care. Formal charges usually include the charges made at the time of services & are typically financed out of pocket. Such costs can be higher, even in the public health care outlets. For example, a recent study in Indonesia found that, facility cost alone can be US $200, which accounts for about 40% of annual disposable income of a household. Therefore, the cost is considerably high for most of the poor women & prevents them from attending skilled & trained practitioners to receive the maternal health care they need.
Informal fees are the payments that are not officially necessary & recognized for providing services but paid for the supplies or to motivate the service providers for better & extra care. In some cases, informal charges may be even higher than the formal charges. One recent study in Dhaka, Bangladesh shows that, where in govt. hospitals services are totally free, the actual cost of a normal delivery amounts to US $32 & a caesarean section amounts to $118.
In some other places, translation cost also poses a significant barrier in attending doctors. Studies show that in Tanzania & Nepal, transportation costs are 50% or even more of the total cost of treatment. Other common observation on practitioners of the development field, show that distance also has an adverse effect on women's for attending doctors & also increases transportation costs, which in many cases deter the poor women's receiving health care services during pregnancy.
Early Marriage: Early marriage of girls often leads them to give birth at early ages, which is more risk prone for the maternal health. And this trend is very common among the low income groups of the poorest countries. Studies show that about 17 million of young women are married before they reach 20 & around 25% to 50% of those young women give birth before they turn to 18. Besides this, poverty, gender inequality & women's low social status as well as disempowerment have impact on women's health, maternal health & necessity of maternal health care services. Lack of education & low social status deprive them of taking timely & proper health decisions. A study in Bangladesh showed that probability of taking any type of health care was 1.73 times higher among the men then that of the women. (source needed or express it differently)
But it is good to know that the trend of early marriage & adolescent birth rate is decreasing day by day all over the world. But there is an important exception also. Between 1990 & 2000, the highest birth rate was recorded in sub-Saharan Africa. Data shows that, in sub-Saharan Africa, adolescents in the poorest households are three time more likely to be pregnant than the girls of the richest families. Besides, the trend of adolescent pregnancy is almost double in the rural areas than the urban areas. And this disparity seems to be linked with education. Girls with at least secondary education are less likely to be early mothers. It is also to be noted that, the birth rate among the uneducated girls is four times higher than the educated girls.
This disparity is widening day by day. Eighteen countries studied in sub-Saharan Africa shows that, the ratio of adolescent birth is decaling only among the girl's with at least secondary education & who belong to the richest households of the urban areas. Therefore the disparity between the rich & poor, educated & uneducated, rural & urban inhabitants is prevailing & even in some cases widening.
Family Planning: By giving the women access to family planning, to delaying or avoiding unintended pregnancies could decline maternal health hazards significantly. According to a recent study (Which study!?), meeting women's need for & access to family planning can reduce 27% of maternal deaths every year, by reducing the number of unintended pregnancies to 22 million from 75 million. In addition, preventing closely spaced pregnancies & adolescent's pregnancies can also improve maternal health & increase the chance that their children will survive.
This trend of women not having access to family planning is present in most regions at moderate to high level. But the situation is intense in sub-Saharan region. There, one in every four woman, aged between 15 and 49, expressed the desire to have access in family planning which they currently don't have. (Source of this info)
But it is challenging to ensure that all poor & uneducated women get the family planning services properly. A survey conducted in 22 sub-Saharan countries revealed that, use of contraceptive to avoid or delay pregnancy is very low among the poor & uneducated women(Source of this info). In those countries, the use of contraceptive is four times higher among the richest women with at least secondary education than those having no education & belonging to poorest households. Finally, it is observed that the disparity among the poor & rich women, the educated & uneducated has not diminished over the period. (Chinmoy you need sources) Regarding the women & maternal health, the following issues are notable-
Difference between Rural and Urban Health Care: With the passage of time, where it is expected to improve the antenatal health condition regardless of urbanization, the scenario has not changed as par expectation. Disparities still exist in the antenatal health care condition, particularly in the Southern Asia, Northern Africa & sub-Saharan Africa. Against 100% women receiving skilled care during the pregnancy(where?), & 90% in the South-Eastern Asia, only 77% get the so in the poorest households.
Though the disparities in the women health care between rural & urban areas has lessen between 1990 & 2008, it has not completely removed. From 1990 to 2008, the proportion of antenatal care has increased from 84 percent to 89 percent in the sub-Saharan Africa. But the ratio has increased at a greater speed among the rural women, from 55 to 66 percent. (Source of this info).
According to WHO & UNICEF specialists, every pregnant woman should receive care from trained & skilled practitioners at least four times during their pregnancies. But unfortunately less than half of pregnant women in the developing regions & only one-third of rural women receive the recommended services. In the Southern Asia, the share is only 25% among the rural women.
Progresses of Maternal Mortality:
Millennium Development Goals (MDGs) have the target to reduce maternal mortality by three-fourths by the year 2015. Though some countries have achieved significant decline in the maternal mortality rate, yet the progress rate is not satisfactory, represents only the 5.5% annually. It is really tough to accurately measure the number of maternal mortality due to the complications of pregnancy & childbirth. However, acceleration in the provision of maternal & reproductive health services to women in all regions indicates that some progresses have been made on the MDG 5.
In almost all of the regions, there has been significant improvement in providing pregnant women antenatal care. And in this aspect, Northern Africa has gained remarkable growth. There the percentage of women meeting skilled worker once a year has increased by almost 70%; whereas Southern Asia & Western Asia reported 50% increment. (Source of this info).
Today maternal mortality reduction has become a national issue. Therefore, different governments are also giving it priority in their population & health policies. For example, since 2003, 11 governments throughout the world in association with UNFPA are fighting to remove Fistula. UNFPA started its campaign in 2006 which worked in 40 sub-Saharan Africa, South Asia & the Arab States. The campaign aims to prevent & treat a terrible childbirth injury called fistula. The disease leaves women incontinent, isolated & ashamed. Nine out of 10 fistulas can be successfully cured. Therefore, UNFPA since the starting of the campaign in 2003, has assisted thirty countries to complete needs assessment. More than 20 countries have already moved from assessment and planning to implement. In this regard, governments in association with private sector supporters are fighting altogether to combat Fistula.
Studies show that in India one woman die in every 5 minutes giving birth. And these deaths occur due to several reasons, such as: poor health, unsafe home delivery, and inadequate access to quality health care. Approximately, more than 100000 women die every year due to childbirth related causes. UNICEF is co-operating the govt. of India, health partners & donors to deal with the situation. And these co-operative initiatives are showing positive signs. For example, over the last four years in Rajasthan, the percentage of deliveries assisted by skilled birth attendants increased by more than 30%. Communities are also responding positively to donate blood during obstetric emergencies.
Maternal Health in Bangladesh:
The maternal mortality ratio in Bangladesh is high, with 320 deaths per 100,000 births. Nearly, 11,000 to 12,000 women dying from pregnancy or childbirth complexity in every year in Bangladesh. This nation has one of the highest rates of adolescent motherhood in the world, based on the proportion of women younger than 20 giving birth every year. One third of the young (13-17) girls in Bangladesh is already a mother. Another 5 per cent are pregnant with their first child. The national figure of maternal mortality for adolescents is double. These high mortality rates are increased due to the fact that nine out of 10 deliveries take place at home with unskilled or untrained attendants. Besides, lower qualities services aggrandize this problem. According to the UNICEF the maternal health scenario of Bangladesh showing the following table. ( Change source, UNICEF, 200.... Maternal health in Bangladesh cited on http://www.unicef.org/bangladesh/MATERNAL_HEALTH.pdf)
Maternal Health in Bangladesh
Basic data Statistics from The State of the World's Children 2007, BDHS and MICS
Maternal mortality ratio (deaths per 100,000 births) Births
Births for women aged 15-19 (per 1000)
Antenatal care coverage (pregnant women attend once, %)
Births delivered at home (%)
Births delivered at a public or private health centre
Delivery assistance from traditional birth attendants (%)
relatives and friends
medically trained providers
Aware of pregnancy complications during pregnancy (%)
Treatment for complications from medically trained provider
did not seek help
*From Bangladesh Maternal Health Services and Maternal Mortality Survey 2001. The State of the World' ChildrenÂ Report 2007 puts MMR at 380. (Clear source).
All after that Bangladesh is on the way to fulfill MDGs. Bangladesh already made a huge progress in fulfilling all the MDGs. Goals number five of MDGs (Maternal Health) is importantly one of them. In 1990-2015 reducing maternal mortality ratio by three quarter but the annual ratio should be reduced by triple. Though trained birth attendance increased during the last fifteen years but its remains lower than the 20% as of 2007. Caesarean birth of child is increasing in the urban areas though not among poor, illiterate rural women. But appropriate quality emergency obstetric care remains in absence in rural areas. The scenario of rural-urban birth attendance is shown in the below tables:
Trends in the use of maternal health services, Bangladesh, 1991-2004
Source of data: Bangladesh Demographic and Health Survey 1993-1994, 1996-1997, 1999-2000, and 2004 (6,8-10); ANC=Antenatal care Object name is jhpn0026-0280_f04.jpg
Trends in pregnancy-related deaths by types in ICDDR, B and government service areas in Matlab, 1976-2005
Note: Maternal death was defined as the death of a woman while pregnant or within 90 days of pregnancy termination Object name is jhpn0026-0280_f02.jpg
It is necessary to take different initiative like family planning and delayed first birth, reducing early marriage, menstrual regulation, and education of women, are also important for achieving MDG. (Reducing maternal mortality and improving maternal health: Bangladesh and MDG 5. Cited on http://www.ncbi.nlm.nih.gov/pubmed/18831225)
Improving Maternal Mortality:
Most of the maternal deaths that are caused by hemorrhage, sepsis, unsafe abortion, obstruct red labor & hypertensive diseases of pregnancy can be prevented by ensuring women's access to reproductive health services, equipment, trained skilled practitioners.
Almost all the regions are realizing the importance of providing the pregnant women antenatal care. Therefore, the percentage of women's attending experts is increasing day by day. In North Africa, the percentage of women who met the doctors at least once during their pregnancy increased by 70%. In this case, Southern Asia experienced 50% increase & Western Asia &70%. (Clear source).
It is also observed that, in 1990 where only 53% of pregnant women in the developing world were meeting being skilled workers, the percentage rose to 63% in 2008. The increment was observed in all the regions but the Northern Africa & South Eastern Africa gained a dramatic increase. In both the regions the increment was 74% & 63% respectively. (Clear source)
Poor women in the remote areas, where the skilled health workers are not available, don't get adequate maternal services. So the mortality rate is very high in those regions. The situation is true particularly in sub-Saharan Africa, Southern Asia & Oceania. (Improve Maternal Health, Goal 5, fact Sheet cited from http://www.mdgmonitor.org/goal5.cfm)
One of the most significant recommendations is to create awareness among the rural poor women regarding their maternal health, nutritious food intake, cleanliness during the pregnancy period. Broadcasting drama, documentation, radio trailer, colorful posters etc can be methods of making aware people, illiterate people in particular.
In Bangladesh since most of the people are illiterate or less literate, women, mothers and family members are needed to aware about cleanliness. Pregnant mothers should be aware about the difficulty what they face during the period and what they should do. Family members, community people should l also be taken into consideration in this regard. Due to ignorance or illiteracy rural people do not know the nitration value of food what they have and for same reason and cooking system, people do not get proper nutrition from cooked food. They should be given clear idea about nutrition value of food, cooking system. Here Radio, Television and print media can be used, even Government take help from local NGOs and international donor agencies also.
Most poor people live below poverty line, it is difficult to maintain their balanced food, and it is very difficult for providing extra nutritious food for pregnant mothers. Government can take programs for providing supporting nutritious food or monthly allowance for buying food.