Maternal health needs a new, pragmatic, research-led approach targeted specifically for developing countries, says Priya Shetty.
Few dispute that pregnant women and their babies should get the best healthcare possible.
Indeed, the Millennium Development Goals include two targets for 2015 under maternal health — to reduce, by three quarters, the maternal mortality ratio, and achieve universal access to reproductive health.
Yet maternal health in the developing world has languished for decades — half a million women die every year from pregnancy and childbirth problems.
Maternal health is never a neutral issue; it is either completely disregarded by cultures that do not value women's wellbeing, or hailed as one of the world's most pressing human rights issues.
But while couching maternal health in these terms may occasionally 'guilt-trip' aid agencies into donating money, it will not secure sustainably funded healthcare programmes. At present, healthcare policies are influenced more by campaigning on human rights and societal duty than by hard scientific data. We need a new approach.
The solution lies in stimulating research to identify the best ways to solve maternal and child health problems, so as to create robust evidence-based policies.
Fifteen years after 'Cairo'
This year marks the 15th anniversary of the 1994 Cairo declaration that called on governments to urgently tackle sexual and reproductive health. Its core premise was that if women are not informed about family planning, allowed to refuse unprotected sex with an HIV-positive man, or protected from practices such as female circumcision, their health will never improve.
The declaration did increase awareness of women's rights, yet in many ways little has changed. This is partly because it is hard to adjust cultural norms about sex and reproduction. For example, even though unsafe abortion kills one woman every eight minutes, many countries cannot reconcile legal abortion with deeply rooted religious beliefs.
Many pregnant women in developing countries have little access to health information. A report by the Guttmacher Institute in New York, which promotes research and policy to improve reproductive health, says that in South Africa, for example, even though abortion was legalised in 1997, in 2000, 40 per cent of women in rural areas still did not know that the procedure was now legal.
The bottom line is that maternal health remains abysmal. That is largely because of the near-absence of research into practical ways to improve it in developing countries. Although much is known about how to make pregnancy and childbirth safe, the knowledge largely comes from developed countries.
And for several years, health researchers have insisted that maternal health can only be improved by bolstering health systems. The brutal truth is that many developing countries are a very long way from having robust health systems, so we need innovative research to find solutions that can work around logistical difficulties in resource-poor settings.
Local researchers also need to work out how to accommodate cultural and religious beliefs into scientific programmes.
One of the rare successes in maternal health has been progress in reducing mother-to-child transmission of HIV, by treating pregnant women and later their newborns. This came not only from drug trials proving the effectiveness of antiretroviral drug nevirapine, but also from research into how to convince women to take the drug — for example, by recruiting traditional birth attendants.
Some argue that limited funding has stalled progress in maternal health. But fixing healthcare systems is too vast a problem for any donor to attempt, and they are rarely given specific research goals. And the goalposts for maternal health have also moved: from solely focusing on labour and delivery, to including newborn care, to integrating all this within a larger healthcare framework.
Volatility in donor efforts is a reflection of this uncertainty. The Cairo declaration should have revitalised donor willingness to fund improvements in maternal health. Instead, although aid for maternal health has risen, it still makes up just three per cent of total healthcare aid.
And aid levels are often unreliable, dropping off when they are needed most. The Countdown to 2015 initiative, which is tracking progress in maternal, newborn and child survival, says several countries that desperately need funds, such as Bolivia, Eritrea and Lesotho, have instead seen donations fall over the past few years.
The good news is that maternal health seems at last to be reappearing as a priority on the global health agenda. At a UN meeting in September, co-hosted by UK Prime Minister Gordon Brown and World Bank President Robert Zoellick, world leaders pledged more than US$5 billion to fund programmes to improve maternal, newborn and child health through, for example, research into vaccines and drugs but also by increasing access to health services.
And next month, a conference of the African Science Academy Development Initiative — a collaboration between United States' and African science academies — will address the challenge of maternal health.
Of the countless rallying efforts to improve maternal health, the conference is one of the first to specifically call for more research. Its agenda states that "the need for dispassionate scientifically-based research and policy advice for improved maternal and child health in Africa is critical".
Crucially, says Barney Cohen, a programme officer at the US National Academies, the collaboration will look at how to increase scientific research designed to influence policy.
The meeting is expected to issue a declaration calling for maternal health research to be tailored to meet challenges in the developing world. "There are many barriers (financial, socio-cultural, transportation) that prevent pregnant women from going to facilities. These require innovative approaches... such as emergency funds, transport schemes, and maternity waiting homes", says Cohen.
"The big problem is how to get these effective treatments out to populations, often in remote areas, in the grip of poverty," says Anthony Costello, a specialist in maternal and child health at the Institute of Child Health, London. "For that we need research about the effectiveness of facility and community delivery systems," he adds.
All aspects of healthcare should have evidence-based policy, but perhaps nowhere is the need clearer than in maternal care. If healthcare professionals start to call for policies based on what is proven to work, rather than advocating what they think should work, mothers in the developing world may not have to wait decades for their health to improve.