Key message: PHAA will undertake a range of activities including -

Public Health Association of Australia: Policy-at-a-glance Maternal Mortality, Social Determinants of Health, Millennium Development Goals in Asia Policy Key message: PHAA will undertake a range of activities including - 1. Advocate to the Federal Minister for Women to work for the safety of women and girls in the developing world. 2. Advocate for the implementation of existing commitments to gender equality. 3. Advocate to the Australian Government and AusAID for: comprehensive provision of accessible and affordable family planning in development aid programmes; skilled attendants at all births; and availability of emergency obstetric care. 4. Advocate for capacity building for health workforces and resourcing to ensuring acceptable quality of care. 5. Advocate for improved data developments. 6. Continue to lobby the Australian Government to raise the AusAID budget to reach the 0.7% of GDP target by 2020. Summary: Maternal mortality continues to be a major challenge to global health systems. The vast majority of maternal deaths are preventable. Maternal mortality is impacted by the social determinants of health: poverty, education, employment, access to health care, health status and gender inequality. Australia is well-positioned to take a leadership role in tackling these issues. Audience: Australian Government and Parliamentarians, AusAID, and relevant international bodies and groups. Responsibility: PHAA s Women s Health, International Health, Political Economy of Health and Primary Health Care Special Interest Groups (SIGs). Date policy adopted: September 2012 Contact: Jaya Earnest, Convenor, International Health SIG j.earnest@curtin.edu.au 1

Maternal Mortality, Social Determinants of Health, Millennium Development Goals in Asia Policy (South Asia, South-East Asia and the Asia Pacific) The Public Health Association of Australia affirms that: 1. Maternal Mortality (MM) - the death of women during pregnancy, childbirth, or in the 42 days after childbirth continues to be a major challenge to global health systems. The largest proportion of such deaths are caused by obstetric haemorrhage, during or after childbirth, followed by eclampsia, sepsis, complications of unsafe abortion and indirect causes, such as violence against women, malaria and HIV. 1 The likelihood of maternal death increases among women with many children, those who are poorly educated, are very young, and subject to gender discrimination. 2. The vast majority of maternal deaths are preventable. Global initiatives to intensify policy intervention for maternal mortality began with the Safe Motherhood Initiative in 1987; a response to growing recognition that primary health-care in developing countries was not adequately focused on maternal health. 2 3. The three delays, that impact on maternal mortality encompass: a) delay in seeking appropriate medical help for an obstetric emergency due to cost, lack of recognition of an emergency, poor education, lack of access to information, poor acceptability of services provided, and gender inequality; b) delay in reaching an appropriate facility for reasons of distance, infrastructure and transport; and c) delay in receiving adequate care when a facility is reached due to shortages in staff, or electricity, water and medical supplies. 3 4. Quality of care is of particular significance. In addition to a delay in attaining care, women are not assured of receiving quality care at facilities. The delivery of poor quality maternity care additionally feeds into the first delay as an influential factor on care-seeking behaviour. 4 5 6 5. Poor maternal nutrition contributes to at least 20% of maternal deaths, and increases the probability of other poor pregnancy outcomes, including newborn deaths. Maternal under nutrition is particularly severe in South Asian countries. 7 6. The Programme of Action of the UN International Conference on Population and Development (ICPD) in 1994 first made explicit the right of every woman to safe pregnancy and childbirth. 8 Childbirth is also more than a biological process; it is a seminal life event for women and it is well established that women s experiences at the time of giving birth are central to their own and their families health and well-being. 9 7. The focus on maternal mortality increased substantially when reduction in maternal mortality became one of eight goals for development in the Millennium Declaration (MDG 5). The target for MDG 5 is to reduce the maternal mortality ratio (MMR) (which is the pregnancy-related death of a woman while pregnant or within 42 days of giving birth and the ratio is the number of maternal deaths per 100,000 live births in a country) by three-quarters from 1990 to 2015 but progress has been slow (countries like Bangladesh and Rwanda have achieved considerable success) and in 10 11 12 some countries the progress has been non-existent. 2

The Public Health Association of Australia acknowledges current global statistics on maternal mortality: 8. As only a third of countries have a complete civil registration system with good attribution of cause of death, 13 other initiatives provide for substantially improved estimates of maternal mortality: The Global Burden of Disease (GBD) study 14 has undertaken a detailed analysis of vital registration data to identify misclassified deaths from causes such as maternal mortality. Second, methodological advances allow for the correction of known biases in survey sibling history data, to note sibling deaths from maternal causes. Third, population-based verbal autopsy studies have been done that measure maternal mortality both nationally and sub-nationally. Fourth, a systematic assessment of data sources for adult female mortality has provided estimates of mortality for women of reproductive age (15 49 years) from 1970 to 2010. 15 9. Global statistics provided by the World Health Organisation (WHO), United Nations Children s Fund (UNICEF) and United Nations Population Fund (UNFPA) and the World Bank estimate that 287,000 maternal deaths occurred worldwide in 2010. The maternal mortality ratio (MMR) in developing countries at 240 deaths per 100,000 live births was 15 times higher than in developed countries at 16 per 100,000 live births. 16 10. For every maternal death, an estimated 20 women suffer pregnancy-related injury, infection or disease, i.e. approximately 10 million women globally. In many cases, long-term disabilities (prolapse, infertility, obstetric fistula or incontinence) result. In developing countries, complications of pregnancy and childbirth are the leading causes of death among adolescents between 15 and 19 years old, with 15 per cent of total maternal deaths worldwide occurring among this age group. 17 11. The maternal mortality ratio (the number of maternal deaths per 100,000 live births) declined globally at a rate of less than one per cent a year between 1990 and 2005. 18 The estimated total number of women dying in pregnancy or childbirth per year decreased only slightly between 1990 and 2005 (from 576,000 deaths in 1990 to 536,000 deaths in 2005). 19 The Public Health Association of Australia notes that human rights approaches are critical to improving maternal health: 12. Three global organizations WHO, UNICEF and UNFPA declared that: The right to life is a fundamental human right, implying not only the right to protection against arbitrary execution by the state but also the obligations of governments to foster the conditions essential for life and survival. Human rights are universal and must be applied without discrimination. For women, human rights include access to appropriate health-care and services that will ensure safe pregnancy and childbirth and provide couples with the best chance of having a healthy infant. 20 13. The 2010 Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternal mortality and morbidity and human rights pursuant to Human Rights Council resolution 11/8 identifies the human rights dimensions of preventable maternal mortality and morbidity in the existing international legal frameworks. It also includes an overview of initiatives and activities to address causes of preventable maternal mortality and morbidity to existing initiatives through a human rights analysis. 21 14. The Committee on Economic, Social and Cultural Rights (CESCR) states that the provision of maternal health services is a core obligation, and that States have the immediate obligation to take deliberate, concrete and targeted steps towards fulfilling the right to health in the context of pregnancy and childbirth. CESCR has emphasized that a State cannot, under any circumstances, justify its non-compliance with the core obligations.. 22 3

15. The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) in 2011 ratified a historic law to establish Nation State obligations to address maternal mortality and morbidity with immediate effect. It requires State parties to ensure services for maternal health and equality and non-discrimination, especially in relation to safety from violence and also in access to health services (art. 12). 23 The Public Health Association of Australia acknowledges the explicit links between the social determinants of health and maternal mortality: Maternal mortality is impacted and influenced by the social determinants of health: poverty, education, employment, access to health care, health status and gender inequality. 1. Gender inequality: stems from power structures in society and is reflected in neglect of reproductive rights, which leads to an unmet need for family planning and increased use of unsafe abortion practices. Violence against women significantly impacts on maternal mortality through physical and sexual violence, lack of contraceptive choice, greater risk of STIs, including HIV and more frequent unwanted pregnancies, adverse pregnancy outcomes or maternal death. 24 2. Racial inequality: links have been established between racism, morbidity and mortality 25, and there is an understood need to ensure services are culturally appropriate for women to ensure uptake. 26 3. Poverty: the link between poverty and health is well known with the poor and disadvantaged more likely to die when compared to the affluent. 27 Critical elements for improving maternal mortality include: a political commitment to provision of appropriate primary health care especially for rural and remote communities; removal of barriers to access free childbirth; the professionalization of midwifery with sustained financial support; improved reporting of births and maternal deaths; and empowerment of women. 28 4. Education: is linked to improved health outcomes through its association with employment, income and living conditions. Educated women seek antenatal care; a trained medical professional to assist them in birth; have incomes through employment; have better nutritional status; are able to identify danger signs during pregnancy; bear fewer children with larger gaps between children; and are more likely to marry later. 29 5. Employment: women in developing countries are more likely than men to be employed in insecure low paying jobs. 30 6. Access to health care: meeting the global unmet need for family planning services would contribute to a 15-20% reduction in maternal mortality in most settings. 31 South Asia has the lowest proportion of women who are attended at least once during pregnancy by a health professional and the lowest proportion that are attended by a skilled health professional during birth. 32 7. Health status: of a woman prior to and during pregnancy influences her chances of developing a pregnancy related complication and her ability to survive the complication. 8 Pre-existing health conditions such as malaria, hepatitis, anaemia, tuberculosis, malnutrition and HIV/AIDS contribute to maternal deaths, however information on the specific contributions is limited 21. The Public Health Association of Australia resolves to undertake the following actions: 1. To strengthen links between the PHAA and Public Health Associations in neighbouring countries, particularly in the Asia/Pacific region. 2. To support links with Global Reproductive Rights Associations and People s Health Movement groups in the region. 3. To advocate with the Federal Minister for Women and Parliamentary Groups to work for the safety of, and to provide opportunity for, women and girls in the developing world. 4. To promote Australia s role in eradicating violence against women, improving protection for women and girls in conflict zones and increasing the representation of women in leadership roles. 4

5. To fully implement commitments to gender equality contained in instruments and plans such as CEDAW and the Australian Government s National Plan to Reduce Violence against Women and their Children (the latter is currently being used by UN Women, the United Nations entity for gender equality and the empowerment of women, as a model for other countries). 6. To advocate with the Australian Government and AusAID for: comprehensive provision of accessible and affordable family planning in development aid programmes; skilled attendants at all births; and availability of emergency obstetric care for those births that need it. 7. To advocate for capacity building of existing health workers and ensure acceptable quality of care, the latter particularly in a timely manner as stimulation of demand for health care services in the 33 34 absence of quality assurance risks increases in facility-based maternal mortality. 8. To assist in building human resources capacity for the maternal health workforce and to support health workforce retention especially in developing countries. 9. To advocate for improved civil registration and other data developments to measure maternal mortality and changes over time. 10. To continue to lobby the Australian Government to raise the AusAID budget to reach the 0.7% of GDP target, supported by the UN, by 2020; to improve development assistance and continuum of care; and to support effective development assistance. References 1. United Nations. The Millennium Development Goals Report 2011. New York: United Nations; 2011. 2. Starrs AM. Safe motherhood initiative: 20 years and counting. Lancet. 2006; 368: 1130 32. 3. UNFPA, response to the note verbale, A/61/338: 2 (para. 21). 4. Ith P, Dawson A, Homer CS, Klinken Whelan A. Practices of skilled birth attendants during labour, birth and the immediate postpartum period in Cambodia. Midwifery. 2012 Feb 16. Available from http://dx.doi.org/10.1016/j.midw.2012.01.010. 5. Chowdhury S, Hossain SA, Halim A. Assessment of quality of care in maternal and newborn health services available in public health care facilities in Bangladesh. Bangladesh Med Res Council Bulletin. 2009 Aug; 35(2):53-6. 6. Van den Broek NR, Graham WJ. Quality of care for maternal and newborn health: the neglected agenda. BJOG. 2009 Oct; 116 Suppl 1:18-21. 7. Countdown to 2015. Building a Future for Women and Children: The 2012 Report. 2012. Available from: http://countdown2015mnch.org/reports-and-articles/2012-report 8. International Conference on Population and Development. Summary of the ICPD Program of Action. March, 1995. Available from: http://www.un.org/ecosocdev/geninfo/populatin/icpd.htm 9. Bayes, S, Fenwick, J, Hauck, Y. A Qualitative Analysis of Women's Short Accounts of Labour and Birth in a Western Australian Public Tertiary Hospital. Journal of Midwifery and Women's Health. 2008; 3 (1): 53-61. 10. United Nations General Assembly. United Nations Millennium Declaration. A/RES/55/2. New York: United Nations; 2000. 11. Obaid TA. Fifteen years after the International Conference on Population and Development: what have we achieved and how do we move forward? Int J Gynaecol Obstet. 2009; 106: 102 05. 12. Hill K, Thomas K, AbouZahr C, et al., on behalf of the Maternal Mortality Working Group. Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data. Lancet 2007; 370: 1311 19. 13. WHO, Trends in Maternal Mortality: 1990 to 2010. WHO, UNICEF and The World Bank estimates. Geneva: WHO; 2012. 14. Naghavi M, Makela S, Foreman K, O Brien J, Lozano R. Algorithms for enhancing public health utility of national causes of death data. Popul Health Metr (in press). 15. Rajaratnam JK, Marcus JR, Levin-Rector A, et al. Worldwide mortality in men and women aged 15 59 years from 1970 to 2010: a systematic analysis. Lancet (in press). 16. WHO, Trends in Maternal Mortality: 1990 to 2010. WHO, UNICEF and The World Bank estimates. Geneva: WHO; 2012. 17. G. Naanda, K. Switlick and E. Lule, Accelerating Progress towards Achieving the MDG to Improve Maternal Health: A Collection of Promising Approaches. Washington, DC, World Bank; 2005, p.4. 5

18. United Nations. The Millennium Development Goals Report. New York: United Nations; 2009. 19. WHO. Maternal Mortality in 2005, p. 2. 20. Reduction of maternal mortality: a joint WHO/UNICEF/UNFPA/World Bank statement. Geneva: WHO; 1999. Available from: http://www.unfpa.org/upload/lib_pub_file/236_filename_e_rmm.pdf. 21. Office of the High Commissioner for Human Rights. Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternal mortality and morbidity and human rights, Advanced edited version, 2010. 22. CESCR. general comment No. 14: The right to the highest attainable standard of health (art. 12). 2000; para. 47. 23. Committee on the Elimination of Discrimination against Women (CEDAW), general recommendation No. 24: Women and health (art. 12). 1999; para. 11. 24. Krantz G, Garcia-Moreno C. Violence against women. J Epidemiol Community Health. 2005 Oct; 59(10):818-21. 25 McKenzie, K. Racism and Health. BMJ. 2003; 326:65. 26 Sabitra Kaphle. Uncovering the Covered: Pregnancy and Childbirth Experiences of Indigenous Women in Remote Mountain Districts of Nepal. Unpublished PhD thesis, Department of Public Health, Flinders University of South Australia. 2012. 27 Ronsmans C, Graham WJ, on behalf of The Lancet Maternal Survival Series steering group. Maternal Survival 1 - Maternal mortality: who, when, where, and why. Lancet. 2006; 368: 1189-200. 28 Liljestrand J, Pathmanathan I. Reducing maternal mortality: can we derive policy guidance from developing country experiences? J Public Health Policy. 2004; 25(3-4): 299-314. 29 Sen G, Ostlin P, George A. Unequal, Unfair, Ineffective and Inefficient Gender Inequity in Health: Why it exists and how we can change it. Final Report to the WHO Commission on Social Determinants of Health: Indian Institute of Management; Karolinska Institutet; 2007. 30 United Nations. The Millennium Development Goals Report. New York: United Nations; 2009. 31 Senanayake P. The impact of unregulated fertility on maternal mortality and child survival. International Journal of Gynaecology and Obstetrics. 1995; 50 Suppl 2: S11 S17. 32 Starrs AM. Safe motherhood initiative: 20 years and counting. Lancet. 2006; 368: 1130 32. 33 Chowdhury S, Hossain SA, Halim A. Assessment of quality of care in maternal and newborn health services available in public health care facilities in Bangladesh. Bangladesh Med Res Council Bulletin. 2009 Aug; 35(2):53-6. 34 Koblinsky MA, Campbell O, Heichelheim J. Organizing delivery care: what works for safe motherhood? Bulletin of the World Health Organization. 1999; 77 (5): 399-406. ADOPTED 2012 This policy was developed collaboratively by the by the Women s Health, International Health, Political Economy of Health and Primary Health Care Special Interest Groups and adopted at the Public Health Association of Australia's Annual General Meeting in September 2012. 6