Educating women is the key to lowering maternal mortality, says major new international study

The fifth Millennium Development Goal (MDG) put forward by the United Nations (MDG-5) proposes to reduce the world's maternal mortality ratio by 75%, by 2015.

But what is the best way of doing this?

International programmes sponsored by the UK and US governments, and delivered under the auspices of international organisations like the UNFPA (UN Population Fund) and IPPF (International Planned Parenthood Federation), focus on the provision of contraception and ‘safe’ abortion as key priorities.

However a new 50 year follow-up study from Chile has literally blown that hypothesis out of the water and demonstrated that the key determinant of maternal mortality is actually the educational level of women.

Furthermore, one of the most significant findings is that, contrary to widely-held assumptions, making abortion illegal in Chile did not result in an increase in maternal mortality. In fact, after abortion was made illegal in 1989, the MMR continued to decrease from 41.3 to 12.7 per 100,000 live births (69.2% reduction).

The result is that Chile is now doing better with maternal mortality than the United States.

Chile offers an opportunity to investigate the influence of these determinants on maternal mortality trends. Not only are large time series of vital and socioeconomic data available for this country that are of similar quality to those of developed countries, but legislation prohibiting therapeutic abortion was passed in 1989.

As a result, data from Chile provide a rare and unique natural experiment to evaluate the influence of population factors, the legal status of abortion and other historical policies on maternal mortality trends since data are available before and after interventions were implemented.

Another recent report has shown how Ireland and Northern Ireland benefit significantly from their near complete ban on abortion in a number of ways.

The report, 'Ireland’s Gain', links Ireland’s low abortion rate to low incidences of breast cancer and comparative good mental health among women when compared with those in England, Scotland and Wales.

The implications for international policy are clear, but will the lavishly funded birth control and abortion industry take note?

I’ve reproduced below the press release from AAPLOG about the Chilean study which gives more of the detail.

Chile Outperforms US and Dramatically Reduces Maternal Deaths by Increasing Women’s Educational Level

A scientific analysis of 50 years of maternal mortality data from Chile has found that the most important factor in reducing maternal mortality is the educational level of women.

‘Educating women enhances women’s ability to access existing health care resources, including skilled attendants for childbirth, and directly leads to a reduction in her risk of dying during pregnancy and childbirth,’ according to Dr Elard Koch, epidemiologist and leading author of the study.

The research entitled ‘Women’s Education Level, Maternal Health Facilities, Abortion Legislation and Maternal Deaths: a Natural Experiment in Chile from 1957 to 2007’ was conducted on behalf of the Chilean Maternal Mortality Research Initiative (CMMRI) and published in the Friday, May 4 issue of PLoS ONE.

Using 50 years of official data from Chile’s National Institute of Statistics (1957-2007), the authors looked at factors likely to affect maternal mortality, such as years of education, per capita income, total fertility rate, birth order, clean water supply, sanitary sewer, and childbirth delivery by skilled attendants. They also analyse the effect of historical educational and maternal health policies, including legislation that has prohibited abortion in Chile since 1989, on maternal mortality.

During the fifty-year study period, the overall Maternal Mortality Ratio or MMR (the number of maternal deaths related to childbearing divided by the number of live births) dramatically declined by 93.8%, from 270.7 to 18.2 deaths per 100,000 live births between 1957 and 2007, making Chile a paragon for maternal health in other countries. ‘In fact, during 2008, the overall MMR declined again, to 16.5 per 100,000 live births, positioning Chile as the country with the second lowest MMR in the American continent after Canada and with at least two points lower MMR than United States’ said Koch.

One of the most significant findings is that, contrary to widely-held assumptions, making abortion illegal in Chile did not result in an increase in maternal mortality. In fact, after abortion was made illegal in 1989, the MMR continued to decrease from 41.3 to 12.7 per 100,000 live births (69.2% reduction). ‘Definitively, the legal prohibition of abortion is unrelated to overall maternal mortality rates’ emphasized Koch.

The variables affecting this decrease included the predictable factors of delivery by skilled attendants, complementary nutrition for pregnant women and their children in the primary care clinics and schools, clean facilities, and fertility. But the most important factor and the one which increased the effect of all others was the educational level of women. For every additional year of maternal education there was a corresponding decrease in the MMR of 29.3 per 100,000 live births.

The picture for Chile includes a transition of leading causes of death along with an accelerated decline of fertility and delayed motherhood. Koch explained that direct causes –those directly attributable to pregnancy condition– were the rule before 1990, but from then, indirect causes –ie. non-obstetric chronic conditions such as hypertension and diabetes among others– rise as the most prevalent, hindering the decline on maternal mortality.

‘This study uncovers an ongoing “fertility paradox” in maternal health: education is the major modulator that has helped Chile to reach one of the safest motherhood in the world, but also contributes to decrease fertility, excessively delaying motherhood and puts mothers on risk because of their older age.’ Thus, an emerging problem nowadays ‘is not a question of how many children a mother has, but a question of when a mother has her children, specially the first of them’ concluded Koch.

Press Release from American Association of Pro Life Obstetricians and Gynecologists (AAPLOG)

A more complete statement on the study by the study's author is available here

Conclusion by Elard Koch, the main author

Taken together, the Chilean natural experiment over the last fifty years suggests that the progress on maternal health in developing countries is a function of the following factors: an increase in the educational level of women, complementary nutrition for pregnant women and their children in the primary care network and schools, universal access to improved maternal health facilities (early prenatal care, delivery by skilled birth attendants, postnatal care, availability of emergency obstetric units and specialized obstetric care); changes in women's reproductive behaviour enabling them to control their own fertility; and improvements in the sanitary system ie. clean water supply and sanitary sewer access. Furthermore, it is confirmed that women's educational level appears to have an important modulating effect on other variables, especially promoting the utilization of maternal health facilities and modifying the reproductive behaviour. Consequently, it is proposed that these strategies outlined in different MDGs and implemented in different countries may act synergistically and rapidly to decrease maternal deaths in the developing world.

By focussing exclusively on HIV/AIDS, malaria and TB, Western governments and NGOs have neglected other easily treatable and curable diseases

Micah Challenge is a global coalition of Christians holding governments to account for their promise to halve extreme poverty by 2015.

It is establishing a global movement to encourage deeper Christian commitment to the poor, and to speak out to leaders to act with justice and its specific focus is the Millennium Development Goals.

The Millennium Development Goals (MDGs) are eight international development goals that all 192 United Nations member states and at least 23 international organizations have agreed to achieve by the year 2015.

They include eradicating extreme poverty, reducing child mortality rates, fighting disease epidemics such as AIDS, and developing a global partnership for development.

The aim of the MDGs is to encourage development by improving social and economic conditions in the world's poorest countries.

The eight MDGs were developed out of the eight chapters of the United Nations Millennium Declaration, signed in September 2000. There are eight goals with 21 targets, and a series of measurable indicators for each target.

Goal 6 is to ‘Combat HIV/AIDS, malaria, and other diseases’ and its three associated targets are as follows:

Target 6A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS
Target 6B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it
Target 6C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases

There are five measurable indicators for target 6C but every single one of them relates to tuberculosis and malaria and none to ‘other diseases’.

So in other words, whilst MDG 6 aims to ‘combat HIV/AIDS, malaria, and other diseases’ the exclusive focus of its associated ‘targets’ and ‘measurable indicators’ is actually HIV/AIDS, malaria and TB. To emphasise the point the United Nations webpage on the MDGs highlights just these three diseases.

The Global Fund to Fight AIDS, Tuberculosis and Malaria is an international financing institution that invests the world’s money to save lives. To date, it has committed US$19.3 billion in 144 countries to support large-scale prevention, treatment and care programs against the three diseases.

It claims as a result, through Global Fund-supported programs, to have saved 5.7 million lives, and put over 2.8 million people on AIDS treatment, 7 million people on anti TUBERCULOSIS treatment, and distributed 122 million insecticide-treated nets for MALARIA prevention.

This is perhaps not at all surprising given the support of wealthy donors and celebrities like Bill and Melinda Gates, Warren Buffet and Carla Bruni. But at the same time virtually no progress has been made on ‘other diseases’. If you don’t identify your target there is little chance of hitting it.

So what are these other diseases? And who is championing their cause?

You, like me, may have missed a series of articles in the Guardian highlighting research that is answering just this question, and giving a platform to the British doctor who has been almost a lone voice in trying to attract the world’s attention to this issue.

In 2005 David Molyneux of the Liverpool School of Tropical Medicine said ‘We urge policy makers and health economists to recognise that although HIV, TB and malaria are the most serious problems facing health planners, other diseases exist that can be addressed at realistic cost with effective interventions. Controlling Africa's neglected diseases is one of the more convincing ways to make poverty history.’

As it seems that no one has listened he has now said it again.

The neglected diseases, which include schistosomiasis, river blindness, ascariasis, elephantiasis and trachoma, affect more than 750 million people and kill at least 500,000 every year.

Treating all of these illnesses with a cocktail of four readily available drugs would cost less than 50 cents (28p) a person a year. Furthermore dealing with the forgotten diseases would reduce susceptibility to malaria and help to make socio-economic improvements for those in poverty, as well as save lives.

Molyneux and his fellow researchers are not saying that we should turn our back on HIV/AIDS, TB and Malaria. Far from it! What he is saying is that they must not be our exclusive focus:

‘We urge policy makers and health economists to recognise that although HIV, TB and malaria are the most serious problems facing health planners, other diseases exist that can be addressed at realistic cost with effective interventions. Controlling Africa's neglected diseases is one of the more convincing ways to make poverty history.’

Reaching everyone in Africa who needed treating would cost $200m a year, a mere fraction of the $15bn a year being spent on malaria, HIV and TB.

However, the plight of these people is being neglected because resources are being monopolised in developing countries by HIV, malaria and TB – even though these diseases infect a much smaller fraction of their populations.

These ‘other diseases’ are being missed because of distorted health policy goals.

‘This is not the fault of pharmaceutical companies,’ says Molyneux. ‘They have made available billions of doses of key drugs. Our problem is that we are not providing the impetus or the means for getting these drugs to disease sufferers. People at policy level think that only malaria, TB and HIV exist in the third world. This is not true. Neglected tropical diseases as a whole – like sleeping sickness or bilharzia – cause more of a burden than these big-name diseases but are being ignored.’

Most major pharmaceutical companies have pledged to provide, at no cost, billions of doses of the drugs needed to combat these diseases. But many G8 governments have failed to provide the means or impetus to get those drugs to the people who need them, a failure which Molyneux says is a major one.

‘If we can't deliver free drugs to poor people, I don't think there is much else we can do in international health’, he said.

Matthew’s Gospel tells (4:23) us that ‘Jesus went throughout Galilee, teaching in their synagogues, proclaiming the good news of the kingdom, and healing every disease and sickness among the people.’

Surely if Jesus himself didn’t focus on just some diseases, but dealt with all, then as his people we must do the same.

I pray that it will not be said of us as a generation of Christian doctors, that whilst making an impact on HIV/AIDS, TB and Malaria we turned a blind eye to ‘other diseases’ like schistosomiasis, river blindness, ascariasis, elephantiasis and trachoma.

The neglected diseases (with numbers affected in sub-Saharan Africa)

Ascariasis Most common human worm infection (173 million)
Schistosomiasis Also called bilharzia. Flatworm infection (166 million)
Elephantiasis Worm infection of lymph system (46 million)
Trachoma Leading infectious cause of preventable blindness (33 million)
River blindness Parasite. Symptoms include eye lesions (18 million)