state of the world's mothers 2010: women on the front lines of health care, may 2010

8/9/2019 State of the World's Mothers 2010: Women on the Front Lines of Health Care, May 2010

1/52

Wmn n h Fn Ln Hlh C

State o the World's Mothers 2010


2/52

2 CHapter titLe goes Here

Contents

2 Fwd by Bd Lynch

3 indcn by Jmn Whbd nd

Chl F. McCmck

5 excv smmy: Ky Fndn nd rcmmndn

9 Wmn Hln Wmn: a pwl Fc

Hlh nd svvl

18 svn Mh nd Chldn n Bnldh

20 a Mdw n evy Vll n indn

22 ovcmn Cll B Hlh C n pk n

24 eh p Fml Hlh Wk n rl aWh thy a Ndd M

26 Dcnlzn Hlh C n tnzn

28 Fhn Mnl Ml y n Hnd

31 tk acn Nw tn M Hlh Wk nd

sv Mh nd Bb Lv

32 andx: 11h annl Mh indx nd

Cny rnkn

37 Mhdly nd rch N

41 endn

Fr cvr

Fn cv: in Mlw, cmmny hlhwk nmd Mdl v h hm mh nd h 5 -dy-ld bby, shnl.Mdl k h bby m, chckn h hlh h mh, nd v dvcb bdn nd c h nwbn.Photo by Michael Bisceglie

sv h Chldn, My 2010.all h vd.

isBN 1-888393-22-X

sv Clr evr o

W fhn v mlln mchldn chnc l. o l

h chvmn Mllnnm Dvlmngl 4, h 5 mlln w chldnd vy y. evy chld h h h vv. eVerY oNe.

Bnldh


3/52

Wmn n h Fn Ln Hlh Cin cmmmn Mh Dy, sv h Chldn blhn lvnh nnl

State o the Worlds Mothers . th c n h ccl h hlh wk n h

dvln wld nd h n nd m ml hlh wk v h lv mh,

nwbn bb nd yn chldn. evy y, 50 mlln wmn n h dvln wld v bh

wh n nl hl nd 8.8 mlln chldn nd nwbn d m ly vnbl

bl c. th dnf cn h hv nvd n nn nd dlyn m ml

hlh wk nd hw hw h wmn dlvn lvn hlh c m

h nd hd--ch mh nd bb. i dnf nd ch h

ccdn n h fh v lv, nd hw h cv ln h chlln

dbl vn n h wld cn.


4/52

2

Fwd

Bridget Lynch

P

I C

Mwv

It is appropriate and compelling that the launch o this report on May 5 coincides with

u I D Mw. W pv within the amily and in communities and health acilities. In both the ormal and

, wv w pv

the community have the greatest potential to improve the reproductive health o women

v v vp w.

Te global community made a commitment in 2000 to create an environment

at the national and global levels alike which is conducive to development and

to the elimination o poverty. Tis commitment led to agreement on eight Millen-

u Dvp G. C MDG 4 5, w

to improve womens reproductive health and reduce maternal and child mortality.

Av w v v w, w

, u u v , u,

equity and poverty reduction. Yet most countries are not on track to meet MDGs 4and 5, which call or reducing maternal mortality by three-quarters and child mortality

w- w 1990 2015. U upp

u v .

We know what is needed to save lives. Proven, cost-eective interventions, delivered

through a continuum-o-care approach, can prevent millions o needless deaths and

disabilities. With a continuum o care approach, women, their newborns and children

have access to essential health services rom pregnancy, through delivery and the

p p u u . Du uu,

o death or mothers and inants is highest during and immediately ater childbirth.

Te continuum o care approach also calls or care that is provided in an integrated

uu , u, p.

Te current shortage o 4.3 million health workers (which includes a shortage o

350,000 wv) v v w

prevent maternal, newborn and child deaths. As this report points out, insufcient

u qu w, qu u p w

conditions all contribute to leaving women and children who are most in need without

v .

Te International Conederation o Midwives is committed to strengthening mid-

wiery around the globe. A midwie is recognized as a responsible and accountable

p w w pp w w pv upp,

care and advice during pregnancy, labor and the postpartum period, to conduct births

and to provide care or the newborn and the inant. Tis care includes preventive

measures, the promotion o normal birth, the detection o complications in motherand child, the carrying out o emergency measures and the accessing o medical care

or other appropriate assistance when necessary. A midwie may practice in any setting,

including the home, community, hospitals, clinics or health units. Te midwie also

has an important task in health counseling and education and amily planning, not

w, u w u.

In this timely report, Save the Children compares the well-being o mothers and

u u w. I u p

sustainable health systems, the emale workorce, which is essential to the provision o

qu u v.

Te challenge beore us is clear. More investment is needed in the appropriate train-

, u qu p upp wv

health providers, so that mothers, newborns and children in the developing world haveaccess to comprehensive, cost-eective, liesaving services. I we want to achieve the

MDG, v w!


5/52

saVe tHe CH iLDreN state oF tHe WorLDs MotHers 2010 3

Every year, our State of the Worlds Mothersreport reminds us o the inextricable link

between the well-being o mothers and their children. More than 90 years o experi-ence on the ground have shown us that when mothers have health care, education and

economic opportunity, both they and their children have the best chance to survive

v.

But many are not so ortunate. Every year, nearly 350,000 women die during preg-

nancy or childbirth, and nearly 9 million children die beore reaching their th birthday.

Almost all these deaths occur in developing countries where mothers, children and new-

borns lack access to basic health care services. While child mortality rates in the developing

world have declined in recent decades, it is o no solace to the 24,000 mothers who must

u v . T p

u pv .

Tis years report looks at how emale health workers in developing countries

are helping to save the lives o mothers, newborns and young children. It highlightswomen-to-women approaches that are working to bring essential health care to the

hard-to-reach places where most deaths occur. It also shows how millions more lives

v v v pv u.

Save the Children is working on our ronts as part o our global newborn and

uvv p:

F, Sv C w u

maternal, newborn and child survival. As part o our campaign, this report calls atten-

w v w v

w, v p p .

Second, Save the Children is encouraging action by mobilizing citizens around the

world to support programs to reduce maternal, newborn and child mortality, and to

advocate or increased leadership, commitment and unding or programs we know work.

T, w j u. Sv C w

in partnership with national health ministries and local organizations to deliver high

quality health services throughout the developing world. Working together to improve

pregnancy and delivery care, vaccinate children, treat diarrhea, pneumonia and malaria,

as well as to improve childrens nutrition, we have saved millions o childrens lives. Te

u v, u w v

u v p w .

Fourth, within our programs that deliver services, we are leading the way in research

about what works best to save the lives o babies in the rst month o lie, who account

or over 40 percent o deaths among children under age 5. Our groundbreaking Saving

Newborn Livesprogram, launched in 2000 with a grant rom the Bill & Melinda GatesFoundation, has identied better care practices and improved interventions to save

w v. T v v 30 w

18 u x w u

w, u v v , p u

w .

We count on the worlds leaders to take stock o how mothers and children are aring

in every country. Investing in this most basic partnership o all between a mother and

p u , ppu

u.

Ev u p. P ake Action p,

and visit our website on a regular basis to nd out what you can do to make a dierence.

indcn

Jasmine Whitbread

C Exuv O

Sv C

Charles F. MacCormack

P CEO

Sv C USA


6/52



7/52


excv smmy

Te most dangerous time in a childs lie is during birth and shortly thereater. Newborn

u w u v 40 p among children under age 5. Childbirth is also a very risky time or mothers in the

developing world, around 50 million o whom give birth each year at home with no

p p wv.

I we want to solve the interconnected problems o maternal and newborn mortality,

w u j w u

p, , u, w w . F v

, p w, p w u w

receive liesaving health care unless there is a emale health worker nearby to provide it.

Tis years State of the Worlds Mothersreport examines the many ways women work-

p v v , w

and young children. It shows how investments in training and deploying emale health

w v p v v v, p w-cost, low-tech solutions that could save millions more lives, i only they were more

w v u.

Key Findings

1. An alarming number o countries cannot provide the most basic health care that

would save mothers and childrens lives. Developing countries have too ew health care

w , u

children. Worldwide, there are 57 countries with critical health workorce shortages,

v w 23 , u wv p 10,000 pp.

Tirty-six o these countries are in sub-Saharan Arica. In addition to insufcient num-

, w p u, w pv, -- z p v. (o read more, turn to pages 10-11.)

2. F w v p p v v

women, newborns and young children. Evidence rom many developing countries

indicates that investments in training and deploying midwives and other emale health

w w u u v v.

Social or cultural barriers oten prevent women rom visiting male health providers even

when they know they or their children are ill and need help. Especially in rural areas,

u w w

care outside the home, and may deny permission i the health worker is a man. And

uqu puv xu

issues, pregnancy, childbirth and breasteeding it is common or a woman to preer aemale caregiver. When women report greater comort and higher satisaction with the

v w, u p v,

and to seek help beore treatable conditions become lie-threatening to themselves and

u . (o read more, turn to pages 12-15.)

3. Relatively modest investments in emale health workers can have a measurable

impact on survival rates in isolated rural communities. It costs a lot o money to train

a doctor or operate a hospital. But in developing countries, liesaving health services can

oten be delivered cost-eectively by community health workers, when given appropri-

upp. W w w

skills needed to diagnose and treat common early childhood illnesses, mobilize demand

or vaccinations, and promote improved nutrition, sae motherhood and essential new-

born care. Tese community health workers are most eective when they are rooted

evr r

8.8 million children die beore

reaching age 5.

343,000 women lose their lives due

to pregnancy or childbirth complications.

d u kw?

41 percent o these child deaths

occur among newborn babies in the frst

month o lie.

99 percent o child and maternaldeaths occur in developing countries

where mothers and children lack access

to basic health-care services.

250,000 womens lives and 5.5 million

childrens lives could be saved each year i

all women and children had access to a

ull package o essential health care.

57 countries have critical shortages

o health workers 36 o them in Arica.

Lb


8/52

6 eXeCutiVe suMMarY

u v w

need their help most. In one recent study in Bangladesh, emale community healthw w u 6 w - u

w u 34 p. (o read more, turn to pages 17-29.)

4. Te most eective health care oten begins at home, or very close to home. Dozens o

studies in remote parts o the world have shown ways to harness the power o women-

to-women relationships to improve health outcomes or mothers and children. In rural

Ethiopia, Malawi, Mali and Senegal, grandmothers have been educated about better

ways to care or newborn babies. And in remote areas o Nepal, India and Bolivia, groups

w v u v p p,

childbirth and newborn care. Improvements as a result o these eorts have included

p , , xuv u-

tions in newborn mortality up to 45 percent. (To read more, turn to pages 14-15 and 18-29.)5. Countries that train and deploy more ront-line emale health workers have seen

dramatic declines in maternal, newborn and child mortality. Bangladesh has reduced

u-5 64 p 1990 w p u

o emale health workers who have promoted amily planning, sae motherhood and

essential care or newborn babies. Indonesia cut its maternal mortality rate by 42 percent

during that same period, thanks in part to its midwie in every village program. Nepal

has achieved similar reductions in maternal and child mortality as result o training

50,000 emale community health volunteers to serve rural areas. Pakistans Lady Health

Workers succeeded in immunizing 11 million women against tetanus inection dur-

, u w u . A Ep

u v w p p x w

to rural villages immunization rates are up, malaria rates are down and more couples

u pv. (o read more, turn to pages 18-25.)

ReCommendations

1. rain and deploy more health workers especially midwives and other emale health

workers.An additional 4.3 million health workers are needed in developing countries to

p v v - Mu Dvp G. Gv-

ments and international organizations should make building health workorce capacity

a priority, particularly the recruitment and training o ront-line emale health care

pv v u .

2. Provide better incentives to attract and retain qualied emale health workers. Bet-ter incentives must be developed to encourage women to become ront-line health

workers and to keep well-qualied emale health workers in the remote or underserved

communities where they are needed most. Tese include better pay, training, support,

protection and opportunities or career growth and proessional recognition. In the

p vp w w p , v

and international organizations must take measures to ensure emale health workers

v v j.

ahnn


9/52


3. Invest in girls education. Increased investments in girls education are essential not

ju p u w w qu w but also to empower uture mothers to be stronger and wiser advocates or their own

health and the health o their children. Educated girls tend to marry later and have

ewer, healthier and better-nourished children. Mothers with little or no education are

u v upp u p ,

.

4. Strengthen basic health systems and design health care programs to better target

p z . Tu

every day in developing countries because health systems are grossly under-unded and

cannot meet the needs o the people. More unding is needed or stafng, transport,

equipment, medicine, health worker training and supportive supervision, and the day-

to-day costs o operating these systems. I children are to survive and thrive, healthoutreach strategies and unding allocations must target the hardest-to-reach mothers

w .

t 2010Mothers Index: nrw tp L, af Rk L, U s Rk 28

Save the Childrens eleventh annualMothers Indexcompares the well-being o mothers and children in 160 countries

more than in any previous year. TheMothers Indexalso provides inormation on an additional 13 countries, 6 o

which report sufcient data to present fndings on childrens indicators. When these are included, the total comes to

173 countries.

Norway, Australia, Iceland and Sweden top the rankings this year. The top 10 countries, in general, attain very

high scores or mothers and childrens health, educational and economic status. Aghanistan ranks last among the

160 countries surveyed. The 10 bottom-ranked countries seven rom sub-Saharan Arica are a reverse image othe top 10, perorming poorly on all indicators. The United States places 28th this year.

Conditions or mothers and their children in the bottom 10 countries are grim. On average, 1 in 23 mothers will

die rom pregnancy-related causes. One child in 6 dies beore his or her fth birthday, and 1 child in 3 suers rom

malnutrition. Nearly 50 percent o the population lack access to sae water and only 4 girls or every 5 boys are

enrolled in primary school.

The gap in availability o maternal and child health services is especially dramatic when comparing Norway and

Aghanistan. Skilled health personnel are present at virtually every birth in Norway, while only 14 percent o births

are attended in Aghanistan. A typical Norwegian woman has more than 18 years o ormal education and will live

to be 83 years old. Eighty-two percent are using some modern method o contraception, and only 1 in 132 will lose

a child beore his or her fth birthday. At the opposite end o the spectrum, in Aghanistan, a typical woman has just

over 4 years o education and will live to be only 44. Sixteen percent o women are using modern contraception, and

more than 1 child in 4 dies beore his or her fth birthday. At this rate, every mother in Aghanistan is likely to suer

the loss o a child.

Zeroing in on the childrens well-being portion o theMothers Index, Sweden fnishes frst and Aghanistan is last

out o 166 countries. While nearly every Swedish child girl and boy alike enjoys good health and education, chil-

dren in Aghanistan ace a 1 in 4 risk o dying beore age 5. Thirty-nine percent o Aghan children are malnourished

and 78 percent lack access to sae water. Only 2 girls or every 3 boys are enrolled in primary school.

These statistics go ar beyond mere numbers. The human despair and lost opportunities represented in these

numbers demand mothers everywhere be given the basic tools they need to break the cycle o poverty and improve

the quality o lie or themselves, their children, and or generations to come.

See the Appendix or the Complete Mothers Indexand Country Rankings.


10/52



11/52


Ev , 9 w u 5

years o age and nearly 350,000 women lose their lives due to pregnancy or childbirthcomplications. Another million babies are lost during the birth process itsel stillborn

u v v w u u .

Most o these deaths occur in areas o the developing world where basic health care

is oten unavailable, too ar away, or o very low quality. And most o these deaths could

be prevented i skilled and well-equipped health care workers were available to serve

the poorest, most marginalized mothers and children. It is estimated that 74 percent

o mothers lives could be saved i all women had access to a skilled health worker at

v p 63 p

under 5 could also be saved i all children were to receive a ull package o essential

health care that includes skilled birth attendance, immunizations and treatments or

pu, . T u 250,000 w 5.5 -

w v u v .F w v p p v v

women, newborns and young children. Evidence rom many developing countries

v u w

w u u v v.

mllu dvlp gl

The Millennium Development Goals

(MDGs) are eight international develop-

ment goals that all 192 United Nations

member states and at least 23 inter-

national organizations have agreed to

achieve by the year 2015. They include

reducing extreme poverty, reducing child

and maternal mortality, fghting disease

epidemics such as AIDS, and developing a

global partnership or development.

The target or MDG 4 is to reduce the

worlds under-5 mortality rate by two-thirds. The target or MDG 5 is to reduce

the maternal mortality ratio by three-quar-

ters. Sixty-eight priority countries have

been identifed that together account or

97 percent o maternal, newborn and child

deaths each year. With only fve years let

until the 2015 deadline, only 16 o these

68 countries are on track to achieve the

child survival goal (MDG 4)6 and only 5 o

the 68 are on track to achieve the targeted

maternal mortality reduction (MDG 5).7

Wmn Hln Wmn:a pwl Fc Hlh nd svvl

sdn

Bnldh


12/52

10 WoMeN HeLpiNg WoMeN: a poWerFuL ForCe For HeaLtH aND surViVaL

Why do We need moRe heaLth WoRKeRs?

Developing countries have too ew health care workers to take on the lie or death

challenges acing mothers, their babies and young children. Worldwide, there are 57

u w w , v w

23 doctors, nurses and midwives per 10,000 people. Making up or these shortages

would require an additional 2.4 million doctors, nurses and midwives. Some o this gap

u w, u w w-

v p , vp w 4.3

w u v.

T-x u w w u-S

Arica, which has 12 percent o the worlds population, 25 percent o the global burden

o disease, and only 3 percent o the worlds health workers. South and East Asia have

29 percent o the disease burden and only 12 percent o the health workers. In contrast, A w u C U S p

9 percent o the global burden o disease, yet almost 37 percent o the worlds health

workers live in this region, which spends more than 50 percent o the worlds nancial

u v .

57 Cur hv t Fw hl Wrkr mk dffrc

fr mr Clr

Whl h n ld ndd n h fcncy h hlh wkc, h Wld Hlh

onzn m h cn wh w hn 23 hlh c nl (hycn, n nd

mdwv) 10,000 ln wll b nlkly chv dq cv h ky m y hlh

c nvnn zd by h Mllnnm Dvlmn gl.13 F xml, hy nlly l chv

n 80 cn cv ml mmnzn h nc klld bh ndn .14 Fy-vn

cn ll blw h hhld; 36 hm n b-shn ac. F ll h cn ch h

lvl hlh wk vlbly wld q n ddnl 2.4 mlln dc, n nd mdwv

lblly. i ll ncy hlh wk ncldd, h lbl h ch 4.3 mlln hlh wk.

Cn wh ccl h hlh wk

Cn wh ccl h hlh wk

a n mrl mrl d

U t Rpr

The State of the Worlds Mothers Report uses

the most up-to-date inormation available

to describe the health o mothers, new-

borns and children around the world. The

data used in this publication come rom a

variety o sources, including ofcial reports

issued by the United Nations and academic

journals. Estimates or maternal mortal-

ity in this report were frst published

online by The Lancet on April 12, 2010 in

an article that included data collected inthe year 2008. Ofcial United Nations

estimates or maternal mortality which

will also include data collected in 2008

are expected to be published in May 2010,

ater this report goes to press.


13/52


In addition to insufcient absolute numbers, health workers are oten poorly dis-

tributed, with the impoverished, hard-to-reach and marginalized populations being

p v. H w u w

hospitals tend to be located, and where incomes are highest. For example, Nigeria

where more than 1 million children die every year beore their th birthday has the

u w u-S A, u j v

u u v p p u w p w .

Problems with too-ew health workers in rural areas oten are compounded by

inadequate pay and insufcient medical supplies, equipment and acilities. Poor work-

ing and living conditions in marginalized areas make it difcult to attract and keep

talented health workers. One survey in South and South-East Asia ound, or example,

that rural postings were shunned by qualied health workers because o lower income,

w p .

Health worker distribution is oten most out-o-sync with human needs in countries

suering rom armed conict. For example, Democratic Republic o the Congo a coun-

try where very large numbers and percentages o women and children are dying has only

32 p u , v u 65 p ppu u.

Country Under-5 Mortality Maternal Mortality Health Workorce Gap

Ranking or

number o under-5

deaths

Annual number

o under-5 deaths

(1,000s)

Ranking or

number o maternal

deaths

Annual number

o maternal deaths

(1,000s)

Ranking or

number o health

workers needed

Estimated shortage*

(1,000s)

ind 1 1,830 1 68 1 515

N 2 1,077 2 37 14 42

Dr Cn 3 554 6 15 6 108

pkn 4 465 3 20 4 202

Chn 5 365 10 7

eh 6 321 5 18 5 167

ahnn 7 311 4 20 12 45

und 8 190 16 5 22 28

Kny 9 189 13 6 16 38

Bnldh 10 183 7 12 3 276

tnzn 11 175 9 8 7 89

indn 12 173 8 10 2 306

5.8 mlln nd-5 dh

= 66% lbl l

227,600 mnl dh

= 66% lbl l

1.8 mlln hlh nl

= 77% lbl l

Cur w m Cl mrl d al hv gr hl Wrkr sr

tw-hd ll nd-5 nd mnl dh cc n j 12 cn. Mny h cn hv vy l ln (ch Chn, ind nd pkn); h

hv vy hh cn chldn nd mh dyn (ahnn nd Dr Cn) nd N h bh l ln nd hh mnl nd chld mly

. th m 12 cn ccn 77 cn h lbl hlh wkc h. D n hlh wk h dc, n nd mdwv.

Hwv, n mny dvln cn, lvn vc ch mmnzn, cncn, nn hbln nd mn nmn, dh nd

ml cn b dlvd by cmmny hlh wk m dbly nd cl hm.

* em ncld h nmb dc, n nd mdwv nly nd clcld h dnc bwn h cn dny nd h WHo-cmmndd mnmm (2.28 hlh

c nl 1,000 ln) mlld by 2009 ln. D c: Under-5 deaths: UNICEF. The State o the Worlds Children, Table 1; Maternal deaths: Hogan, Margaret , et al.

Maternal Mor tality or 181 Countries, 1980-2008: A Systematic Analysis o Progr ess Towards Millennium Development Goal 5. The Lancet. Publishe d online April 12, 2010; Health work orce density :

WHO. Global Health Atlas (http://apps.who.it/globalatals /); 2009 population: UNFPA. State o World Population 2009.


14/52


Why FemaLe heaLth WoRKeRs?

Te most dangerous time in a childs lie is during birth and shortly thereater. Newborn u w u v 40 p

u 5. C v

developing world, around 50 million o whom give birth each year at home with no

p p wv. P u w, p

living in rural areas, are ar less likely to give birth in the presence o a skilled health

w u w w v w u.

I we want to solve the interconnected problems o maternal and newborn mortality,

w u j w u

p, , u, w w . F v

, p w, p w p

childbirth care be provided by a woman. Evidence is also mounting that the quality

w--w up. W w p comort and higher satisaction with the care they receive rom other women, they

u p v, p

- v u .

Social or cultural barriers oten prevent women rom visiting health providers even

w w p w . I u Su A,

Middle East and Arica, women typically are not empowered to make independent

decisions. Especially in rural areas, husbands and elder amily members oten decide

whether a woman may go or health care outside the home. Although women are

usually the rst to notice their own and their childrens health problems, they must

overcome hurdles o decision-makers within the household, which can result in sig-

nicant delays in seeking care and sometimes in denial o permission altogether. Tese

- xp w xp p w v .

When there is no emale health care provider available, the likelihood increases

that a woman will be denied permission to seek health care. And women themselves

oten choose to orego health care i the provider is male, due to embarrassment or

:

A 2009 analysis oDemographic and Health Surveysrom 41 developing countries

ound that nearly one quarter o women listed not having a emale health provider

v .

An assessment inAghanistan ound that women were unable or unwilling to

v p v u x v u w

u xp v.

I was afraid to go to the hospital to have mybaby because I had never been to a hospital before.

Also my husband and his family would not allow

me to have my delivery with a male doctor.Naseem, -- v I


15/52


A u Ep u w wu

or malaria was that the community health workers were male and the women pp xu .

While the gender o a health care provider is not always a critically important actor,

, w v w w w

pv , u . F

health concerns that are uniquely emale those related to reproductive or sexual issues,

pregnancy, childbirth and mothering it is common or a woman to preer a caregiver

who shares her experiences. Many women report higher levels o satisaction with

emale health workers, who they see as more responsive to their needs and the needs o

their children. And when emale health workers are nearby and easily accessible, more

w w w .

In Brazil, a study ound that emale health workers spent longer in consultationwith children under age 5 (an additional minute, on average) than their male coun-

p. T w w v pu pv

who had been trained in a new set o interventions with the potential to reduce

u-5 .

In northern Ghana, emale nurses were relocated rom subdistrict health centers to

isolated rural communities where child mortality rates were well above the national

average. Te nurses had been trained to prevent and treat common childhood

diseases, promote sae motherhood, provide basic midwiery services, antibiotics,

v pv, u w w

located miles away rom rural households, their services were underutilized and

their impact was minimal. Te communities subsequently provided housing or

Wr tr ar mr hl Wrkr, mr mr

Clr survv

sc: WHO. World Health Report 2006, p.xvi

MaterN

aLsurViVaL

CHiLD

surV

iVaL

iNFa

Ntsu

rViVa

L

Dny hlh wkLw Hh

Hh

probability

ofsurvival


16/52


the nurses so they could live close to the people they served, and the government

provided additional training to enable the nurses to organize community health

services, build community relationships and supervise volunteers. Ater three years,

u-5 u w u .

In many countries in Latin America, as well as several in Arica and Asia, emalehealth workers and hospital-based volunteers teach mothers o underweight, pre-

term babies to use a technique called kangaroo care to save their babies lives.

T v u u, p x

w u qu. A vw 15 u-

vp u u w v u

care, cutting newborn deaths by 51 percent or preterm babies who were stable.

Te ndings suggest that up to hal a million newborns could be saved each year

i kangaroo care were used everywhere, especially in low-income countries where

w .

T u - pv w w p

u, xp w uu p . H

at home, and it is mothers, grandmothers, older sisters and other close relatives and

riends who provide it. Recent studies have looked at ways to harness the power o

women-to-women relationships to improve health outcomes or mothers and children.

Su v p v p, -- u w

people are more likely to become ill, less likely to get appropriate treatment, and oten

xp p .

In Nepal, emale acilitators organized monthly meetings where women gathered to

solve shared problems related to pregnancy, childbirth and care o newborn babies.

Te groups devised their own strategies to tackle challenges, and the result was more

prenatal care, more trained birth attendance, more hygienic care, and dramatically

w w .

Ml


17/52


Te same approach was tested in very poor areas oIndia. Te groups were acili-

tated by women recruited in the local area who tended to be married with someschooling, were respected members o the community, but were not health care

proessionals. Again, the results were dramatic: by the second and third years o the

, w w pp w up

existed had allen by 45 percent. Tese areas also saw a signicant drop (57 percent)

in depression among mothers. Tere was a move away rom harmul practices

such as giving birth in an unclean environment and delaying breasteeding, said

P A C Iu C H Uv C

London. We saw signicant improvements in areas such as basic hygiene by birth

, w p .

In rural areas oEthiopia, Malawi, Mali and Senegal, grandmothers oten wield

considerable power within amilies and make critical decisions about what chil- w v.

Harmul traditional practices have been passed down or generations; or example:

delaying breasteeding or up to 24 hours ater birth and introducing harmul oods

and liquids during the rst six months when it is recommended that babies be

exclusively breasted. In all our o these countries, grandmothers have been edu-

cated about better newborn care practices, and are making changes within amilies

p pv u, uvv u .

Ruc mrl mrl a

Three Asian countries oer dramatic

examples o how sustained political will

to provide better health care has saved

mothers lives. Since the 1950s, Malaysia,

Sri Lanka and Thailand have each reduced

their maternal mortality rates by an

astonishing 97 percent.38 In Sri Lanka, or

example, the odds that a woman will die

due to complications o pregnancy and

childbirth have decreased rom 1 in 95 to 1

in 3,333 live births.39,40And in Malaysia, the

odds have dropped rom 1 in 187 to 1 in2,381.41,42

How did these countries do it? Each

o them made equity a guiding principle

and put in place policies and systems to

ensure ree or low-cost health care would

reach the poorest, most disadvantaged and

isolated communities.

Another key component o these

Asian successes was putting women on

the ront lines o health care. For example,

Malaysia and Sri Lanka invested in mid-

wives, increasing their numbers and statuswith well-run training and certifcation

programs.43 Thailand instituted a success-

ul sae motherhood program that made

skilled birth attendance nearly universal

by 2001. Thailand also trained many more

nurses and midwives, growing their num-

bers rom about 10,000 in 1971 to 85,000

in 2002.44

ind


18/52


What aRe the ChaLLenges?

Why are there not enough emale health care workers to provide liesaving care to

mothers and children in developing countries? And why is it especially difcult to

place emale health care workers where they are needed most in the poorest, most

z u?

One reason is the persistently poor quality o education or girls. Worldwide, 39

million girls are not attending school and countless millions more complete only a

year or two o schooling. Tese educational shortalls among girls tend to be most

pronounced in impoverished rural areas. When local girls do not have the basic educa-

tional qualications to enter training to become nurses, midwives or even community

w, u p u

p, p u.

Saety and quality-o-lie concerns oten prevent emale health workers rom livingalone in isolated rural areas. I the health worker is single, her parents may be reluctant

to let her work ar away rom home. And i she is married, her spouse may not want to

v u w p ppu

.

Te International Labour Organization has noted the high risk o violence and

unair wage dierentials common among nurses and midwives. Violence and sexual

harassment o emale health proessionals in developing countries has been understud-

ied, but is believed to be widespread. Te lack o a sae workplace compromises the

health and well-being o emale sta as well as the amilies they serve. In particular, the

lack o personal saety at health posts and other ront-line health acilities oten staed

w w u p 24

hours a day. And yet, round-the-clock coverage is precisely what is needed or obstetric - .

Many o the best qualied health workers leave developing countries to pursue

better pay and higher standards o living overseas. For example, 34 percent o nurses

wv Zw 85 p u P-

pp w w . Lw, w w u,

u u , w , p - u. I

, p u u.

Community health workers should be members

of the communities where they work, should

be selected by the communities, should be

answerable to the communities for their activities,

should be supported by the health system but not

necessarily a part of its organization, and have

shorter training than professional health workers.World Health Organiation

Zmbbw


19/52


What aRe the soLUtions?

Increased investments in girls education are essential not just to enlarge the pool

u w w qu w u pw

uu w v w

o their children. Educated girls tend to marry later and have ewer, healthier and

better-nourished children. Mothers with little or no education are much less likely

to receive skilled support during pregnancy and childbirth, and both they and their

.

M p, vu w w u pp-

u v v p w uu . T

include not being able to read inormation about good health practices, lack o sel-

condence and authority to make decisions, and inability to negotiate with authorities

or services. Since discrimination against girls is known to begin early, promoting genderequality and respect or the rights o women and encouraging athers to play an active

u w u p.

In order to address critical shortages o health workers and persistent inequities

in the way they are distributed, governments and international organizations must

pz u - pv v

v . T pv-

u qupp ppp u u.

Better incentives must be developed to keep ront-line health care workers in these

remote communities where they are needed most. Tese include better pay, training,

upp, p ppu w p .

Where personal saety is a concern, governments and international organizations

must go the extra distance to ensure emale health workers do not have to risk theirlives in order to do their jobs. For example, in Aghanistan, security has been provided

to acilities where women health providers work at night, and male amily members

p w w v. A U, -

lowing reports o midwives being attacked on their way home rom work at night, there

have been renewed calls or the government to make good on its promise to provide

u w pv w.

Health workers in developing countries do not need to be highly educated to be

eective. Experience in many countries has shown that community health workers

with a ew years o ormal schooling can master the skills needed to deliver basic health

interventions, including diagnosing and treating common early childhood illnesses,

z v v A, p w

health and nutrition practices. Especially in isolated rural areas where education levelstend to be low and where it is highly desirable to have health workers who are rooted in

u - u p

qualications to enhance the likelihood that local girls can be recruited and trained to

w, uu Np P.

Governments should set targets to reduce disparities in health care provided to

rich and poor citizens and reduce maternal and child mortality rates across income

and social groups. Tis should occur with an overall eort to strengthen health sys-

u , -v - p v

clear national policies with ongoing commitment including unding to achieve

.

ahnn


20/52

18

svn Mh nd Chldn n Bnldh

Bangladesh has made tremendous strides in maternal and child health over the past 30

years. Between 1990 and 2008, under-5 mortality declined 4 percent and Bangladesh v Mu Dvp G uvv. B-

u u p 53

p. S, 11,600 120,000 w

in Bangladesh, mainly because o inadequate care during childbirth. Te country

does not have enough skilled birth attendants and 82 percent o deliveries occur at

wu pp .

I B w

having babies beore their bodies have ully matured. In rural areas, 69 percent o

emales are married beore they turn 18. Large numbers o women in Bangladesh

have no say in their own health care needs 48 percent say their husbands alone make

.

Mu B p u u p-tion, which has enabled couples to choose smaller, healthier amilies. Starting in the

1970s, the government and NGOs organized more than 35,000 emale eldworkers to

go door-to-door oering amily planning inormation and contraceptive services. In

uu w w w p v , p v

o services by a woman was key to the eorts success. Studies suggest the program also

pv w u . T p w

every hamlet in Bangladesh showed that women were employable, mobile, socially

u uu. Yu pu

encounters and received inormation and services that would otherwise not have

been available to them. Cultural norms began to change, and by the 1990s many

Bl Vl sc

1 child in 15 dies beore age 5

57% o these deaths are newborn babies

Lietime risk o maternal death: 1 in 51

1 doctor or every 3,330 people

Health worker shortage: 275,700*

* D h dc, n

nd mdwv. Hwv, n mny dvln

cn, lvn vc ch mmnzn,

cncn, nn hbln nd mn

nmn, dh nd ml cn b dlvd

by cmmny hlh wk m dbly nd

cl hm.

Bnldh


21/52


more women who wanted amily planning supplies were able to leave their homes

.In 1997, the government launched a sae motherhood initiative aimed at improving

emergency obstetric care and training 17,000 skilled birth attendants to work at the

community level. Family planning was integrated into a broader package o health

services that includes prenatal and postnatal care, child immunization and disease

pv.

B v w NGO w p-

cies towards international organizations. For example, the indigenous NGO BRAC

currently supports a health program that includes 70,000 emale community health

workers providing services to 31 million people in rural areas. Also, Pathnder Interna-

tional is now partnering with Grameenphone and 30 local NGOs on a sae motherhood

p upp u u-

services to poor amilies. o date, more than 1,500 pregnant women and 13,000 inantsv v u p.

Te Projahnmo Project, supported by Save the Children, the Bill & Melinda Gates

Fu USAID, u w pv p-

tal and postnatal care during home visits in rural areas with high newborn mortality

. T w - u

w . A u, w w u 34 p.

T w u w w w

education and training can have a signicant impact on newborn survival. Based on

u, - u- pj p pv

w uu u B.

54,000 Fl Vlur fr hl

Cr i

In 2000, the state o Chhattisgarh was cre-

ated when the large central Indian state o

Madhya Pradesh was divided. Chhattisgarh

had high levels o poverty and illiteracy, and

inherited a weak public health system with

too ew acilities and too ew sta. The

rural inant mortality rate was the second

highest in India.67

To combat these challenges, the gov-

ernment and civil society representatives

established a strong team o 54,000 wom-en community health volunteers called

Mitanins (riends in the local language).

These volunteers come rom the com-

munities they serve. Many are not ormally

educated, but they have been trained to

dispense drugs, provide nutrition counsel-

ing, manage childhood illnesses, provide

essential newborn care and identiy danger

signs that require prompt reerral to a

health care acility or proper treatment.68

Independent surveys show that the

rural inant mortality rate in Chhattisgarhdecreased rom 85 deaths per 1,000 live

births in 2002 to 65 in 2005. In addition,

the initiation o breasteeding within

two hours ater birth increased rom 24

percent to 71 percent, and the use o oral

rehydration salts or diarrhea in children

under 3 increased by 12 percent.69

The success o theMitanins has also led

to advances or women in Chhattisgarh,

individually and collectively. ManyMitanins

have entered elected ofce and have led

community actions to establish early child

care acilities, secure tribal livelihoods,

and fght deorestation, corruption and

alcoholism.70

I could share everything with Mahmuda

because she was a woman too. Only a woman

knows how another woman feels in certain

situations. If Mahmuda was not there,

I might have had a fatal health hazard. With

Mahmudas guidance and care, my baby

was born safe. Mrahan, 45-- v B

Mhmd


22/52

20

a Mdw n evy Vll n indn

I 1989, 19,500 w I u p-

u p . , u 9,600.Tese womens lives were saved largely as a result o the governments investment in

w v v p. Ov v , I ,

and certied 54,000 new village midwives. Each received three years o nursing

training ollowed by a year o midwiery training beore being posted to their villages.

Tere are now approximately 80,000 midwives in Indonesia; however, despite this prog-

ress, women still die in higher numbers than women in other countries in the region.

Te midwives many equipped with a small birthing room at their house or clinic

provide outreach and reproductive health services, immunizations and counseling

about proper nutrition. Tey were initially given a three-year contract or their services,

, - .

Te midwie program includes a mechanism or public eedback, and the gov-

ernment has responded to criticisms by adapting its strategy, modiying the trainingcurriculum, doing clinical audits to improve the quality o midwie services, and

pv .

i Vl sc





Health worker shortage: 305,900** D h dc, n nd mdwv.Hwv, n mny dvln cn, lvn vcch mmnzn, cncn, nn hblnnd mn nmn, dh nd ml cn bdlvd by cmmny hlh wk m dbly ndcl hm.

indn


23/52


I 125,600 u w w u u . S

u v ppu, u v u u wv, I pu p v

v wv u.

Between 1991 and 2007, the percentage o Indonesian births attended by skilled

personnel more than doubled, increasing rom 32 percent to 79 percent. Indonesia

also lowered both its maternal and newborn mortality rates by more than 40 percent

p 100,000 v 1989 228 2007

32 w p 1,000 v 19 u p.

While there has been progress in institutional deliveries over time, inequities

between rich and poor continue to be a problem. A recent study in two districts in

West Java ound that nearly 70 percent o Indonesias wealthy women gave birth with a

health proessional, compared to only 10 percent o the poorest women. Te poorest

wealth quintile in Indonesia still has a very high maternal mortality rate estimated 706 p 100,000 v .

Fl Cu hl

Vlur npl

Nepal is a difcult place to be a mother.

Especially in rural areas, it is common or

girls to marry in their teens and begin hav-

ing children beore their bodies have ully

matured. More than 80 percent o births

occur at home without the presence o

skilled health personnel and 1 woman in

31 dies due to complications o pregnancy

and childbirth.

Though Nepal has a long way to go, itis moving in the right direction. For nearly

two decades the country has been system-

atically strengthening its health systems by

investing in services or mothers, children

and newborns. Nepal cut its maternal mor-

tality rate nearly in hal between 1990 and

2008.85 The under-5 mortality rate has also

declined rapidly, alling 64 percent in that

same time period.86

A key component o these successes

has been the recruitment, training and

deployment o 50,000 Female Community

Health Volunteers (FCHVs) who play an

important role in a variety o key public

health programs in rural areas, including

amily planning, maternal care, child health,

vitamin A supplementation, deworm-

ing, and immunization coverage. FCHVs

educate and inorm women about birth

preparedness, make post-partum visits, and

treat and reer children with pneumonia

and diarrhea.87

Te community health volunteer is nearby.

Whenever I need her, she is there. During my

pregnancy, she has come to see me frequently

so I do not have to walk all the way to the

health post. Yemna, , p w Np


24/52

22

ovcmn Cll B Hlh C n pkn

Social, cultural and religious traditions severely restrict the reedom o Pakistani women

and have made it imperative that Pakistan put emales on the ront lines o health care , w .

Pakistani women have a subordinate status in society, especially in rural areas, where

they are expected to stay at home. In one recent survey, interviewees repeatedly said:

W j - , v p

w . T j w p u

unaccompanied and an overwhelming majority o rural women report the need or

p, p u , v .

P N P F P P H C

v , L H W w pv

percent o the countrys population, mainly those in rural areas who or cultural reasons

cannot leave their homes. Te program, launched in , delivers essential primary

health care to amilies through emale community health workers who go door-to-doorpv v w w w .

Pk Vl sc






pkn


25/52


S qu L H W -munity they will serve, be at least years old, have successully completed middle

school education, and be recommended by the residents o their community as a good

candidate. Married women are given preerence. Tey receive months o training (

u-, p-), u p

hygiene, community organization, interpersonal communication, data collection and . O , v

upv v w.

Te Lady Health Workers treat diarrhea and pneumonia, and make reerrals or

more serious conditions. Tey provide prenatal and postnatal care to mothers, provide

contraception to couples, conduct basic health education and help coordinate services

such as immunizations and anemia control. Research has shown a clear connection

w p L H W pv u . Independent evaluations have ound substantial increases in childhood vaccination

rates, child growth monitoring, use o contraception and prenatal services, provision o

iron tablets to pregnant women and lowered rates o childhood diarrhea. Signicant

reductions in inant and maternal mortality have also been documented in areas served

L H W.

In , Save the Children, UNICEF, JICA and the government o Pakistan

launched a campaign to ght maternal and newborn tetanus, a deadly inection caused

by unsae but common childbirth practices such as using a dirty blade to cut the

umbilical cord. Some , newborn babies were dying each year rom tetanus in

Pakistan deaths that could be prevented by giving every pregnant woman two shots

u x w v w- p.

A public awareness campaign used advertisements, brochures, videos and posters toeducate women about the liesaving benets o tetanus toxoid immunizations. Special

events were held at clinics on the days that shots were given and Lady Health Workers

w v w wu

v w . T p u uz

w u u .

I p p w , v-

ment o Pakistan launched its National Maternal, Newborn and Child Health Program

in . A key strategy in the plan is to train and deploy , midwives to rural com-

munities within ve years. Te rst class o trainees graduated in early . More than

, community midwives are now in place, and over , are currently in training.

We used to lose many children to pneumonia.But now, when children get even minor colds,

their parents bring them to us for a check-up.

Tey are not afraid of the illness like before,

because they know their children can be cured

quickly. Saira, L H W P

mwfr tr af

Aghanistan is one o the riskiest places

on earth or the health o mothers and

children. Only 14 percent o births are

attended by skilled personnel and maternal

and child mortality rates are among the

highest in the world. Aghan women ace

a 1 in 8 risk o dying rom complications

during pregnancy and childbirth, and 1

child in 4 dies beore reaching age 5.

In response to this tragedy, the

Ministry o Public Health (with support

rom USAID) launched a program torapidly train and deploy midwives to rural

areas where there had been little access to

ormal health care. Since 2002, the number

o midwiery schools in Aghanistan has

increased rom 6 to 31. About 2,400

midwives have been trained and are now

employed by the government and NGOs

across the country, most o them in ser-

vice to their home communities.100 Largely

as a result o this eort, the percentage

o women in rural Aghanistan receiving

prenatal care increased rom 5 percent in2003 to 32 percent in 2006, while deliver-

ies attended by skilled personnel increased

rom 6 percent to 19 percent in the

same period.101 An additional 300 to 400

midwives are being trained each year.102

An estimated 8,000 to 10,000 are needed

to provide basic obstetric services or all

Aghan women.103, 104

The government is also stepping

up eorts to train and deploy women

community health workers (CHWs). An

estimated 22,000 to 84,000 emale CHWs

are needed (this calculation varies depend-

ing on whether each CHW is assigned to

40 households or to 150 households). The

total number o CHWs (emale and male)

trained to date is 5,000, representing 22.7

percent o the target at best.105


26/52

24

eh p Fml Hlh Wk nrl a Wh thy a Ndd M

I Ep, , w u p u

pregnancy or childbirth and more than , each year suer rom pregnancy-related disabilities. An estimated 321,000 children die each year beore reaching

127,000 w .

T v , pp Ep

doctors are located in urban centers, while percent o the population lives in

rural areas. Health systems and inrastructure are seriously underdeveloped, and

transportation problems are severe, especially during the rainy season. Almost all births

take place at home ( percent) without a health proessional and child in dies

.

Te government o Ethiopia is now tackling these challenges head-on with an ambi-

u w p pz . W

support o several external donors, a program was launched in to train and deploy

emale health extension workers to rural villages. Some , o these HEWs are nowin place, each with a years training in basic health services such as sae childbirth,

essential newborn care, diarrhea treatment, hygiene and sanitation, malaria prevention

and treatment, and health education. Under a new policy approved in February

, the HEWs will also be trained to provide antibiotics to treat pneumonia, the

ep Vl sc






eh


27/52


largest killer o children in Ethiopia. In addition, nearly , health posts have

u, w , p.

Preliminary evaluations show the HEWs are having a positive impact on the health

o the communities they serve. Improvements have been documented in immunization

, pv u . T v

u pv u pv qu . M

people are constructing and using latrines, and disease outbreaks are reported more

p f.

Some questions have been raised about the quality o the one-year training program

or the HEWs. Studies also point to persistent shortages o skilled nurses and doctors to

provide back-up support to the health workers. Resource limitations such as supervi-sors, medical equipment and supplies may also hinder the impact on key indicators.

Health extension workers report they are generally content with their work and

motivated by adequate salaries, housing and the availability o sae water and toilet

acilities. However, one study ound that only percent o HEWs expect to stay more

than three years in their current position. While most nd their work ullling, they

say they hope to be promoted to better positions in nursing or environmental health.

Te female health workers understand theproblems we have. I like it when they come

to my home and talk to me about hygiene,

sanitation and how to breastfeed my children.

Men do not understand all the situations we

face as women. Birke, 25-- w Ep

Vll hl t U

In Uganda, 1 woman in 25 will die in preg-

nancy or childbirth, and each year 44,000

newborn babies die in the frst month o

lie.120While Uganda has made progress

in reducing maternal and newborn death

rates in the past two decades, the country

still has a long way to go.

Uganda has many maternal and

newborn health policies, strategies and

interventions in place, but they have

not been well disseminated, integratedor implemented. Some o the greatest

opportunities to strengthen health care

in Uganda lie at the community level with

innovative interventions, such as a new

program to deploy Village Health Teams.121

These teams are made up o nine to

ten members, at least three o whom

must be emale. They are selected rom

and by their communities, and many

already have experience as community

health workers, change agents or peer

educators. They receive additional training,

depending on their role, in areas such as

malaria treatment and management o

childhood illnesses. A recent analysis by

the Ugandan Ministry o Health, UNICEF

and Save the Children recommends one

member o the team also be trained in

home-based care or newborns.122


28/52

26

Dcnlzn Hlh C n tnzn

Each year in anzania, , newborn babies die and an additional , are

stillborn. Most o these babies die rom preventable or treatable causes, and it is esti-mated that up to two-thirds (, to ,) could be saved i essential care reached

all mothers and newborns. Te situation or mothers in anzania is also perilous.

More than hal o all births take place at home, and it is estimated that woman in

w u p u p .

Te government o anzania has responded with a number o policies and strategies

to improve the health and survival o women and children. Free services are now oered

to all women during pregnancy, delivery and the post-natal period, and to children

under the age o . Te government has also launched national nutrition policies

u.

anzania has done an unusually good job o positioning health workers close to

people who need them in remote areas. Eighty percent o nurses and percent o

wv u . I , w w u than they are in urban areas, despite higher incomes, education levels and better health

services in the cities (this may be explained by higher prevalence o HIV and AIDS

u ).

tz Vl sc






tnzn


29/52


Nu wv p w

percent o all skilled deliveries, and percent o all pregnant women receive pre-natal care rom a nurse or midwie. Cesarean deliveries are commonly perormed by

f w .

z v w (VHW) p p w

VHWs in each village, one o whom is to be responsible or maternal and child health,

while the other is responsible or environmental sanitation. At least one VHW is

required to be emale. Te VHWs assist pregnant women with birth planning, which

includes knowing danger signs, preparation or clean delivery and saving money to

p .

Despite these eorts, the percentage o births attended by skilled proessionals

has declined over the past decade, alling percentage points rom to /

(rom to percent). On other ronts, however, anzania is showing progress.

N v p w ( p) w p v.T p w p u p

, p. A w xuv

x w p u , v p

p /.

anzania is also challenged by a rapidly growing population, while its overall health

workorce is shrinking ast. In 1994, there were 7,00 health workers or a population

29 , u u 25,000 w ppu

o more than 40 million. anzania has one doctor or every 25,000 people overall,

u v 100,000 pp.

I had severe bleeding and my mother-in-law

refused to let me go to the hospital. She told me

it was normal. I told her the nurse said severe

bleeding is a risk sign. Finally, she let me go.

Te doctor said if I hadnt come, I would

have died. Om Mohamed, 27-- Ep

scl Up mwfr nr

Nigeria aces considerable challenges

with its large population, high birth rate,

widespread poverty and inadequate health

systems. Sixty-one percent o births occur

at home without skilled assistance142 and

36,700 women and girls die each year as a

result o complications during pregnancy or

childbirth.143The lietime risk o maternal

death is 1 in 18. Babies also die at high rates,

with a total o 283,000 newborns perishing

every year in the frst month o lie.144

The government o Nigeria together

with international partners and support

rom the U.S. and U.K. governments is

attempting to meet these challenges with

a new Integrated Maternal, Child and

Newborn Health Strategy designed to

rapidly recruit and train health workers,

roll out proven health interventions and

build health inrastructure.

One component o the plan aims to

increase the number o births attended by

a trained midwie.145 Until recently, there

were ew public health centers oering

24-hour care and many health centers

did not have a qualifed midwie. Currentand retired midwives have been called to

action and given additional training or

emergency obstetric and newborn care.

As o January 2010, more than 2,800 mid-

wives had been sent to rural villages.146The

programs goal is to continue to scale up,

frst to 5,000 midwives and then to 10,000

by 2012.147To ensure adequate numbers

o midwives in the system, girls and young

women are to be identifed and sponsored

or midwiery training, with a requirement

that they return to their communities towork or three to our years aterwards.148


30/52

28

Fhn Mnl Mly n Hnd

Between and Honduras achieved one o the most rapid reductions in mater-

nal mortality ever recorded in the developing world. Over this period, Hondurasadvanced rom having rates o maternal mortality as high as deaths per ,

live births, to having relatively low maternal mortality o deaths per ,

v p u ju v .

Over roughly the same period, Honduras under- mortality rate ell by percent

(rom to deaths per , live births). Tis rate has continued to all to a low o

p p u v. S, Hu

remains a country with some o the highest maternal, under- and newborn mortality

L A.

S -, Hu v p -

tives to provide better prenatal care or pregnant women and training to traditional

birth attendants. It also created aster and more aordable ways or women to reach

w w u p.Hu u w p u

with special training in obstetrics who provided basic care or routine childbirths. Most

had transport available in case o emergencies that required hospital care. Birthing

homes are less expensive to maintain than hospitals and bring skilled attendant care

p w v -- .

hur Vl sc






Hnd


31/52


Honduras also established maternity waiting homes. Tese were built near hospitals

to provide a place or women rom remote areas to go near the time o delivery so u v . Yu, - ,

w v w u -

cal conditions were reerred to these waiting homes in anticipation o a higher risk

v. u w, w

u f , w w

ppp.

oday the primary vehicle o Honduras maternal and child health strategy is the

Community-Based Integrated Child Care Program (AIN/C). Tis program utilizes

community volunteers monitoras who can be men, but are usually women. Te

p u u w

v.

Despite this progress, Honduras is one o only a handul o Latin American countrieswith a critical shortage o health personnel, and those that exist are disproportionately

concentrated in urban areas. While the majority o prenatal and delivery care is pro-

v , p p

, p u w p .

Elena has helped me a lot. I feel more secure

when she visits me and gives me advice.

Maybe its because she is a mother like I am.Jacinta, 33-- u Gu

tr Blv iu mr

W Rpc

Bolivia is one o the poorest countries

in Latin America with some o the high-

est maternal and child death rates in the

hemisphere. Inadequate health care dispro-

portionately aects rural indigenous women,

who oten avoid going to medical acilities

because they ear mistreatment due to their

gender, ethnicity and traditions.

In the early 1990s, a project called

Warmi organized rural women into

groups to identiy and address their health

problems. It also trained birth attendants

and husbands in sae birthing techniques.

Warmi succeeded in increasing the propor-

tion o women receiving prenatal care and

breasteeding on the frst day ater birth.160

The Warmi approach has served as a model

or other successul initiatives in Nepal,

India, Zambia and several Latin American

countries.161

PROCOSI, a network o 33 NGOs, has

been working or more than two decades to

promote gender sensitivity as a necessary

component o high-quality care. PROCOSI

has set standards to certiy clinics as gendersensitive, thereby increasing women's satis-

action and use o services.162

These eorts, along with successul

amily planning programs, contributed to

a dramatic 59 percent decline in maternal

mortality in Bolivia between 1990 and

2008.163

Bolivia has virtually no proessional

midwives164 due to the cancelation o its mid-

wiery program in the 1970s.165 However, the

government recently pledged its support or

a new generation o midwives to be trainedat three rural universities.166


32/52



33/52


tk acn Nw tn M HlhWk nd sv Mh nd Bb Lv

Every year, nearly 9 million newborn babies and young children die beore reaching

5 350,000 w v u p -p.

An additional 4.3 million health workers are needed in developing countries to help

save these lives and meet the health-related Millennium Development Goals. Tese

w u p 2012.

heLP Us saVe the LiVes oF motheRs, ChiLdRen and BaBies

aRoUnd the WoRLd.

Citizens everywhere should urge their governments national governments and

v up v Mu Dv-

p G 4 5.

Donor countries and international agencies must keep their unding commitments

v MDG 4 5. W u pp G-8 Su

in June 2010 in Canada to double total G-8 bilateral aid or maternal, newborn

.

Developing country governments must commit to recruiting and deploying the

additional health workers especially emale health workers needed to deliver

v v , w u .

A v u v Auj 2001

to devote at least 15 percent o government spending to the health sector. Tis must

include resources or the implementation o a national action plan or maternal,

newborn, and child health that is supported by accountable leadership and goodwp u.

All governments should commit to a Global Action Plan on maternal, newborn

and child health to be adopted at the September United Nations Summit on the

Millennium Development Goals in order to accelerate progress on MDGs 4 and 5.

Governments, donors and international agencies should make the education o

girls a priority, which will empower and enable mothers to be better caretakers and

p u w w qu w.

J Sv C w uvv p.

VisitWWW.saVetheChiLdRen.net to Find the CamPaign inyoUR CoUntRy and join oUR moVement.

Lb


34/52

32 appeNDiX: tHe MotHers iNDeX aND CouNtrY raNKiNgs

Te eleventh annualMothers Indexhelps document conditions or mothers and children

in 10 countries developed nations6 and in the developing world and showswhere mothers are best and where they ace the greatest hardships. All countries or

w uf v u Index.

W u Sv C w ? Bu

90 xp v u u qu v p

on the health, security and well-being o their mothers. In short, providing mothers

w u, ppu

v uvv v.

Te Indexrelies on inormation published by governments, research institutions and

. T Complete Mothers Index, p p

indices or womens and childrens well-being, appears in the old-out table in this

appendix. A ull description o the research methodology and individual indicators

pp -u.

motheRs index RanKings

European countries along with New Zealand and Australia dominate the top

p w u u-S A w . T U

S p 28 .

While most industrialized countries cluster tightly at the top o the Index with

j u p w

countries attain very high scores or mothers and childrens health, educational and

u.

Te 10 bottom-ranked countries in this years Mothers Indexare a reverse image

o the top 10, perorming poorly on all indicators. Conditions or mothers and their

u v.

Sx p p.

O v, 1 23 w p- u.

1 6 .

1 3 u u.

Ru 1 5 p .

O 4 p v 5 .

toP 10 best places to be a mother Bottom 10 worst places to be a mother

Rank Country Rank Country

1 Nwy 151 eql gn

2 al 152 e

3 iclnd 152 sdn

3 swdn 154 Ml

5 Dnmk 155 Dr Cn

6 Nw Zlnd 156 Ymn

7 Fnlnd 157 gn-B

8 Nhlnd 158 Chd

9 Blm 159 N

9 gmny 160 ahnn

andx:th Mh indx nd Cny rnkn

Nc


35/52


W nubr d tll yu

The national-level data presented in the

Mothers Indexprovide an overview o

many countries. However, it is important

to remember that the condition o geo-

graphic or ethnic sub-groups in a country

may vary greatly rom the national average.

Remote rural areas tend to have ewer

services and more dire statistics. War,

violence and lawlessness also do great

harm to the well-being o mothers and

children, and oten aect certain segments

o the population disproportionately.These details are hidden when only broad

national-level data are available.

O v, v v 5 u.

W 40 p w qu w.

N u 10 w u .

Te contrast between the top-ranked country, Norway, and the lowest-ranked

country, Aghanistan, is striking. Skilled health personnel are present at virtually every

birth in Norway, while only 14 percent o births are attended in Aghanistan. A typical

Norwegian woman has over 18 years o ormal education and will live to be 83 years

old, 82 percent are using some modern method o contraception, and only in 132

w . A pp pu,

A, p w ju v 4 u w v

44. Sx p w u p, 1

child in 4 dies beore his or her th birthday. At this rate, every mother in Aghanistan u .

T Mothers Indexu u p w

rich and poor countries and the urgent need to accelerate progress in the health and

w- . T -

. T 10 u A S v

u-S A. Su-S A u 16 20 w-

u.

Individual country comparisons are especially startling when one considers the

u u :

Fewer than 15 percent o births are attended by skilled health personnel in Chad

A. I Ep 6 p . Cp

99 p S L 94 p Bw.

1 woman in 7 dies in pregnancy or childbirth in Niger. Te risk is 1 in 8 in Aghani-

stan and Sierra Leone. In Bosnia and Herzegovina, Greece and Italy the risk o

1 25,000 I 1 47,600.

A p w w 50 C A Rpu, D-

ocratic Republic o the Congo, Mali, Mozambique, Nigeria, Sierra Leone and

Zambia. Lie expectancy or women is only 46 in Lesotho, Swaziland and Zim-

babwe. In Aghanistan, the average woman does not live to see her 45th birthday

w Jp w v v v 86 .

In Somalia, only 1 percent o women use modern contraception. Rates are less

5 p A, C Gu. E p w Norway, Tailand and the United Kingdom and 86 percent o women in China

u p.

In Aghanistan, Jordan, Lebanon, Libyan Arab Jamahiriya, Morocco, Oman, Paki-

stan, Syria and Yemen, women earn 25 cents or less or every dollar men earn. Saudi

A P w 16 12 pv

dollar. In Mongolia, women earn 87 cents or every dollar men earn and in Mozam-

qu 90 .

In Belize, Comoros, Micronesia, Oman, Saudi Arabia, the Solomon Islands and

Qatar, not one seat in the lower or single house o parliament is occupied by a

woman. In Bahrain, Papua New Guinea and Yemen, women have only one seat.

Compare that to Rwanda where well over hal 5 percent o all seats are held by

w. I Sw, w 46 p p .


36/52

34 appeNDiX: tHe MotHers iNDeX aND CouNtrY raNKiNgs

A typical emale in Aghanistan, Angola, Chad, Djibouti, Eritrea and Guinea-Bissau

v v u. I N, w v our years. In Australia and New Zealand, the average woman stays in school or

v 20 .

F-v p Dju Ppu Nw Gu

in primary school. Out-o-school rates are 48 percent in Eritrea. In comparison,

Au, Bu, F, G, I, N,

Sp Sw p w .

In Central Arican Republic and Chad, ewer than 3 girls or every 4 boys are in

p . I A Gu-Bu, 2 v 3 .

1 child in 5 does not reach his or her th birthday in Angola, Chad, Democratic

Republic o the Congo and Somalia. In Aghanistan, child mortality rates are higher 1 4. I F, I, Luxu, Sp Sw, 1

333 5.

Over 40 percent o children under age 5 suer rom malnutrition in Bangladesh,

M, Np, N Y. I I -L,

up v uw.

More than hal o the population o Chad, Democratic Republic o the Congo,

Equatorial Guinea, Ethiopia, Fiji, Madagascar, Mozambique, Niger, Nigeria and

Papua New Guinea lack access to sae drinking water. In Somalia and Aghanistan,

71 78 p ppu, pv, w.

Statistics are ar more than numbers. It is the human despair and lost opportunities

behind these numbers that call or changes to ensure that mothers everywhere have the

pv pv qu

v, , .

Frqul ak Qu abu mr i

Why doesnt the United States do better in the rankings?

The United States ranked 28th this year based on several actors:

One o the key indicators used to calculate well-being or mothers is lietime risk o

maternal death. The United States rate or maternal mortality is 1 in 4,800 one

o the highest in the developed world. Thirty-fve out o 43 developed countries

perormed better than the United States on this indicator, including all the Western,

Northern and Southern European countries (except Estonia and Albania) as well as

Australia, Bulgaria, Canada, Czech Republic, Hungary, Japan, New Zealand, Poland,

Slovakia, and Ukraine. A woman in the Unites States is more than fve times as likely

as a woman in Bosnia and Herzegovina, Greece or Italy to die rom pregnancy-related

causes in her lietime and her risk o maternal death is nearly 10-old that o a woman

in Ireland.

Similarly, the United States does not do as well as many other countries with regard

to under-5 mortal ity. The U.S. under-5 mortality rate is 8 per 1,000 births. This is on

par with rates in Slovakia and Montenegro. Thirty-eight countries perormed better

than the U.S. on this indicator. At this rate, a child in the U.S. is more than twice as

ahnn


37/52


likely as a child in Finland, Iceland, Sweden or Singapore to die beore his or her fth

birthday.

Only 61 percent o children in the United States are enrolled in preschool making it

the seventh lowest country in the developed world on this indicator.

The United States has the least generous maternity leave policy both in terms o

duration and percent o wages paid o any wealthy nation.

The United States is also lagging behind with regard to the political status o women.

Only 17 percent o seats in the House o Representatives are held by women,

compared to 46 percent o seats in Sweden and 43 percent in Iceland.

Why is Norway number one?

Norway generally perormed as well as or better than other countries in the rankings on

all indicators. It has the highest ratio o emale-to-male earned income, the highest contra-

ceptive prevalence rate, one o the lowest under-5 mortality rates, and one o the most

generous maternity leave policies in the developed world.

Why is Afghanistan last?

Aghanistan has the highest rate o under-5 mortality, the lowest emale lie expectancy

and the worst gender disparity in primary education in the world. Perormance on most

other indicators also place Aghanistan among the lowest-ranking countries in the world.

Why are some countries not included in the Mothers Index?

Rankings were based on a country's perormance with respect to a defned set o indica-

tors related primarily to health, nutrition, education, economic and political status. There

were 160 countries or which published inormation regarding perormance on these

indicators existed. All 160 were included in the study. The only basis or excluding coun-

tries was insufcient or unavailable data or national populations below 250,000.

What should be done to bridge the divide between countries that meet the needs of their

mothers and those that dont?

Governments and international agencies need to increase unding to improve

education levels or women and girls, provide access to maternal and child health care

and advance womens economic opportunities.

The international community also needs to improve current research and conduct

new studies that ocus specifcally on mothers and childrens well-being.

In the United States and other industrialized nations, governments and communitiesneed to work together to improve education and health care or disadvantaged

mothers and children.


38/52

36

2010 Mh indx rnkn

Country MothersIndex Rank*

WomensIndex Rank**

ChildrensIndex Rank***

TIER I: More Developed Countries

Nwy 1 2 9

al 2 1 28

iclnd 3 5 6swdn 3 7 1

Dnmk 5 4 19

Nw Zlnd 6 3 24

Fnlnd 7 6 18

Nhlnd 8 9 22

Blm 9 11 13

gmny 9 14 3

ilnd 11 8 26

Fnc 12 13 4

sn 13 15 11

und Kndm 14 10 24

swzlnd 15 18 12

slvn 16 12 20

en 17 19 13

ily 17 24 2

pl 19 22 8

Cnd 20 17 21

Hny 21 15 23

Lhn 22 21 27

Czch rblc 23 27 13gc 24 26 17

Lv 25 19 33

a 26 33 5

C 27 25 32

und s 28 23 34

Lxmb 29 34 9

plnd 29 29 29

slvk 31 30 30

Jn 32 38 6

Bl 33 28 36

Bl 34 31 31

Ml 35 41 13

sb 36 40 35

rmn 37 32 39

rn Fdn 38 35 38

ukn 39 37 37

Mldv, rblc 40 38 41

Bn nd Hzvn 41 36 43

Mcdn, tFYr 42 42 40

albn 43 43 42

TIER II: Less Developed Countries

Cb 1 1 10

il 2 2 2

ann 3 4 13

Bbd 3 3 2

K, rblc 5 6 7

Cy 6 8 1

uy 7 7 8

Kzkhn 8 9 21

Bhm 9 12 5

Mnl 10 4 53

thlnd 11 10 19

C rc 12 21 12

Chl 13 20 4

Clmb 13 10 33

Bzl 15 15 19

sh ac 16 14 51

p 17 18 31

Chn 18 13 42

ecd 18 17 40

Vnzl, Blvn rblc 20 16 34

Dmncn rblc 21 19 26

Mxc 21 26 18

uzbkn 23 23 36

Bhn 24 26 17

Kyyzn 25 24 38

pnm 26 21 39

tndd nd tb 27 34 25

tn 28 36 14

Jmc 29 30 29

Kw 30 30 27

M 31 35 27

Vnm 31 24 57

Blv, plnnl s 33 29 52

py 34 28 54

amn 35 36 37

snm 36 38 47

Nmb 37 30 65

Country MothersIndex Rank*

WomensIndex Rank**

ChildrensIndex Rank***

TIER II: Less Developed Countries (Continued)

Mly 38 45 22

Q 39 49 9

s Lnk 40 33 60el slvd 41 39 56

in, ilmc rblc

state of the world's mothers 2010: women on the front lines of health care, may 2010

Documents