Maternal Health and Foreign Policy Symposium, Session 1: Framing the Issue

Tuesday, June 27, 2006

Speakers

Lynn Freedman

Associate Professor of Clinical Population and Family Health, Mailman School of Public Health, Columbia University

Geeta Rao Gupta

Executive Director, International Center for Research on Women

Presider

Isobel Coleman

Senior Fellow for U.S. Foreign Policy, Council on Foreign Relations

ISOBEL COLEMAN: Hello, everybody. Thank you so much for coming today on this very hot and muggy day. We’re very pleased to have you here at this important symposium, looking at the issue of maternal health.

I’m Isobel Coleman. I’m a senior fellow for U.S. foreign policy here at the Council on Foreign Relations, and I also direct the Women and Foreign Policy Program here. And, together with my colleague Laurie Garrett, who is a senior fellow for global health at the Council, we have put together this program today, two panels back to back; the first looking at the issue why is it that more than half a million women in the world today die in childbirth. That’s one element of maternal health, and it’s the unseemly element of maternal mortality. Getting pregnant for many women in many countries in the world today is the most dangerous thing they can do.

And we are so pleased to have with us today two experts on this topic for our first panel, and then two more that Laurie will moderate in the afternoon. The first is, on my far left, is Geeta Gupta, Dr. Geeta Gupta, who is the head of the International Center for Research on Women, based in Washington, D.C. And ICRW is a leading authority on many different women issues around the world. And Geeta’s organization does a range of research on issues looking at the status of women in developing countries, with I think the motto of “if you don’t measure it, you can’t change it.” And health is a very important aspect of it, and Geeta herself is a noted expert on the whole HIV/AIDS epidemic in the world too. So we are so pleased to have you with us today.

And our second speaker is Lynn Freedman, who is the director of the Averting Maternal Death and Disability Program, professor of clinical population and family health at the Mailman School of Public Health at Columbia University. And when I was trying to shape this program along with Laurie, Lynn was one of the first people I turned to to understand what is it that we’re talking about on maternal health. And so we are so pleased to have you with us here today also to speak about this.

I just want to take this opportunity to remind everyone this is on the record. We are aggressively on the record. We hope to get lots of attention coming out of this meeting for these issues, which are underserved and underresearched and underrecognized in the world. So we are on the record.

If you could take this moment to turn your cell phones off, so we don’t have those interruptions during the course of the afternoon.

And the format today is we’re going to have a conversation for about a half an hour up here, and then open to questions from the audience on these topics. And then we’ll move directly into the second panel and have a short reception afterwards, which will allow even further conversation.

I’d just like to start out by asking both of our panelists this question: Why is it that today, at the start of the 21 st century, getting pregnant is so dangerous in so many parts of the world? More than half a million women die in childbirth every year. And the debilitating consequences of childbirth for nearly nine million women can be life altering and life threatening, and really change them and change the prospects for the rest of their life in fundamental ways.

So we’re talking about a very, very large number of people who are deeply negatively affected by childbirth and pregnancy. And it just seems that in today’s day and age that shouldn’t be happening. So perhaps we can start with you, Lynn, and just give us your perspective on this.

LYNN FREEDMAN: Well, why is it still happening? It’s important to recognize that that 500,000 number has basically not changed since we first started measuring it. So it’s really important to recognize it’s not only a big number, but it hasn’t changed.

And the answer to why and why it hasn’t changed is obviously many layered, and I thought maybe if I—if this panel was to frame the issue, maybe I should make a few sort of epidemiological comments about the nature of that number. First, I think it’s really important—I was going to say three things shape maternal mortality and why it hasn’t changed.

One is maternal mortality is not very sensitive to many of the changes in environmental factors or quality of life that can be very important, let’s say, for child mortality. So, for example, changes in nutrition or environmental health don’t change maternal mortality very much—that’s one. Two, what does change it is access to health services. And so the second fact I think that shapes this issue is the fact that we actually know what to do to save women and if—we have the technical means to address the complications that kill women. So basically the second issue is that we have the technical solution.

The third thing I would say is there’s a difference between the number of deaths and the maternal mortality ratio, which is essentially the safety of giving birth. So family planning can be critically important to changing the number of deaths. And it’s pretty simple: if you don’t get pregnant you won’t die in childbirth. But it has very little to do with the safety of giving birth once you do get pregnant.

So my first kind of level of answer—and I’m sure we’ll get to many levels in the next half hour—is women die because we let them die, because we have the means to stop them from dying, and they mostly come from access to the health services that can address the complications that kill women. So that’s I think a fundamental point: access to the kinds of health services that can treat the complications that kill women.

GEETA RAO GUPTA: And if I can just add to that and broaden it a little, because access to health services is the key to ending maternal mortality, society’s view of women having access to different resources makes a big difference. So in many, many societies around the world women have unequal access to reproductive resources and to services, to health services. And that, as you can imagine, that inequality affects then the outcomes from each pregnancy. So while it may not be a direct or what we call a proximate cause, it is a very important contextual reason why women suffer. It’s also the reason why the problem hasn’t been attended to, despite the fact that we’ve known what to do about it. So the fact that women are unequal means that women then get less investments in most countries for their well-being, which is one of the reasons why, despite the fact that this is such a shocking statistic, we have made so little progress with it.

COLEMAN: The number half a million—and I’m rounding here—it’s really 529,000 women estimated to die in childbirth. And if you look at that number, 95 percent of that number is concentrated in two parts of the world, South Asia and sub-Saharan Africa. And this goes back to the point that we’ve got a maternal mortality ratio that in some countries is very, very high, and that’s true in sub-Saharan Africa; and, in South Asia, in particular in India, the maternal mortality ratio is not as bad—not quite as bad as some sub-Saharan Africa countries, but they have so many births that it really contributes to the very high number. So can you help us understand how should we think about this problem? India, which I think a woman who gets pregnant in India has a one out of 48 chance of dying in childbirth. In sub-Saharan Africa it’s about one out of 10 on average, ranging one out of six in some countries to one out of 15, but it roughly averages in that one out of 10.

GUPTA: That’s compared to one in 2,200 or something like that—

COLEMAN: One in 2,500 in this country.

GUPTA: In this country, right.

COLEMAN: And one in 2,900 in some Scandinavian countries. So I mean we’re talking massive differences in your outlook on getting pregnant in these different places. So maybe just help us understand as we’re framing this problem—South Asia versus sub-Saharan Africa.

FREEDMAN: You know, I think WHO actually developed a very interesting way of looking at this. You raise the question of—I mean, we can see globally inequity is a huge problem. And sometimes we just talk about inequity as though it’s the same everywhere. But WHO actually developed a way of talking about it that I think is really helpful that goes a little bit to this. The difference between a country or a region where inequity is along the lines of what they call massive deprivation, the vast majority of people don’t have access and a small number do, and they have a—they draw a graph showing that; versus inequity that they call marginal exclusion, where many people do have access, but some portion of the population is actually excluded. And I think it’s not the full answer, but maternal mortality is I think dependent very much on inequity.

I think one of the ways of thinking about the difference between very high MMR countries and high MMR countries is in part this difference between massive deprivation; that is, massive inaccess to these kinds of services that can save your life, versus some access but more marginal exclusion—bigger or smaller margins, but still a kind of marginal exclusion. And I think that means that we have different kinds of problems. I think that’s a social problem.

GUPTA: I think in a country like India—and I can speak on the record on India, because I was born there— India is actually quite shocking given the fact that they have a fairly well structured, well set up health system that they have been unable to bring the MMR down in terms of numbers. The number of women dying in childbirth is quite massive and quite shocking.

I don’t think there’s any excuse in India for, especially now with the amount of economic growth it’s enjoying, to not attend to this problem right away. I think the part of the reason why as a global community we have perhaps failed in attending to this better than we should have, especially in countries like India where the resources are more available than in some countries in sub-Saharan Africa. It’s because some of the solutions we provided early on as a global health community were the wrong ones, or were not the ones that would take care of the problem in a big way like we wanted it to. So, you know, a few years ago—I can’t remember how many decades ago—there was the whole focus on training traditional midwives and making sure that they had traditional birth attendants, that they had the skills and the tools to be able to attend to childbirth in a hygenic way. But they weren’t skilled enough to be able to attend to emergencies that first need either immediate action or immediate referral. And the transportation and referral system isn’t necessarily the easiest for them to be able to do that. Nor did they always recognize risks even when they were trained in the way they should have.

So we spent a lot of effort then, I feel as the global health community, focusing on that, because we thought it would be the low-cost way to deal with the problem. We knew that women were in any case delivering a lot of their babies outside the hospital setting. In India training traditional dais, as they’re called, was a huge investment by the government, but it didn’t give us the results we wanted, because it was the wrong solution.

And then we sort of went down the track of prenatal care. You know that antenatal care, if it’s done right, can actually identify women who are at risk, the at-risk pregnancies, and then if we can target them and really tend to them. But what we failed to understand was that actually every pregnancy is an at-risk pregnancy, because emergencies can develop like that; and, if not attended to immediately with the right level of care, can result in death. So I think that that was another misstep.

So it’s just my sense that if you put that aside now and think about the number of years that we have known that emergency obstetric care, a good referral system and skilled attendants at birth of a particular level of skill are essential, the fact that the investment hasn’t been made goes partly to the mentality of donors and government to try to seek quick, low-cost, simple solutions they think, rather than understand that this is about a health system as a whole that needs fixing. It requires an investment to provide emergency obstetric care that may be quite large. It needs the health system to be coordinated for the referral system to work. And all of those things can take some time, certainly some coordination, enormous amounts of leadership and lots of resources.

FREEDMAN: And if I can jump in, when we talk about health systems, I mean I think one of the things that those of us here, and Mary Robinson will be on the next panel, who come from the human rights perspective, are increasingly trying to make the argument, and I think convince policy makers in the world that health systems are actually major human rights issues; that we need to see health systems not just as technical systems where you get all the pieces of the puzzle and then it works like a machine. But these are really social institutions where all the dynamics of power and inequity and gender issues and all of that play out. And there aren’t formulaic solutions for that. There are things that work better than other things. But it’s really about building on a responsive society, responsive social institutions that respond to many things, including this problem.

COLEMAN: Geeta, you refer to the training of midwives and the low-cost solutions as missteps. Was that fair, that they were missteps? Or were they necessary but simply not sufficient?

GUPTA: That’s probably a better way of stating it. And perhaps you know they did make some dent in the maternal mortality that resulted from just unhygienic situations. But it’s not enough to make the bold move—

COLEMAN: You can’t stop there.

GUPTA: Yeah.

COLEMAN: So my question behind that is: Are there any silver bullets out there, either in the India context where there is a functioning health system but women don’t have the access that they would needs to those services and also what’s missing are those emergency care? And what about in sub-Saharan Africa, the other part of this problem, where there isn’t a functioning health system? Are there any things that we can be doing that maybe they’re not quick wins but that they can make a dent in this problem as we ponder those and begin to address those long-term solutions that you referred to as being—

GUPTA: I don’t think there’s a silver bullet, even in a country like India. And just to make the point, India has a system, but it doesn’t necessarily always work, and it’s not of high quality. So there’s a lot of room for improvement there. And it’s boring stuff. It’s about management, it’s about supervision, it’s about inventory control, it’s about supplies, it’s about pricing, you know, it’s about incentives for staff—it’s a whole bunch of things that are much less sexy than a technology or a type of training module, or something that can just be bought and then scaled up. And therein lies the problem.

But I think that the way to make the case for that investment is that when you strengthen that you not only address maternal mortality, but you address a lot of the other health issues that the poor face. So it requires some creative solutions for transportation, for thinking about private sector involvement, thinking about ways in which this can be sustained by funding other than just government funding. But ultimately it’s the dirty work of just attending to business that we should have attended to a long time ago to improve health overall. And I think in part that will then address definitely the case of maternal mortality.

And just to add to that goal, in India you have the additional problem of enormous gender inequalities. So in terms of the first most important thing is for when a woman is in trouble during a pregnancy that that trouble is recognized and somebody attends to the fact that she needs to get to a service. When women are not valued, and young girls are not valued and don’t have a voice, at that very first step they lose out. So if they’re not valued—so there is an underlying inequality problem in India where daughters are valued less, where some preference is very strong, where women—and I may be stating it more strongly than it’s true—are somewhat dispensable—that becomes a problem to even get to that first step where the health system then can take care of the rest.

COLEMAN: Go ahead.

FREEDMAN: I think it’s important to not think of Africa as not having a health system.

COLEMAN: Yes.

FREEDMAN: No, I think in one sense is there’s many countries in Africa that have a health system that often even used to work better than it does now. And there are a number of—I wouldn’t call them silver bullets or magic bullets, but there’s a number of very important solutions that have been developed in Africa by African governments, African professionals, that I think are important parts of the solution.

A key one of them relates to human resources and who actually can do these kinds of life-saving services. I know Allan Rosenfield will be on the next panel, and he’s really one of the leaders in this whole issue, this whole question of who should be allowed, trained, legally supported to do obstetrics. And some of the most creative and important solutions to that have actually come out of Africa by African professionals in African systems. So, you know, while different systems are at different levels, there’s no place that we’re starting at zero. And I think there’s always something that can be done on the short, medium and long term.

COLEMAN: This is a good lead-in to my next question, which Geeta I think you—or, I’m sorry, one of you referred to—maybe it was you, Lynn—about following a—not listening to the indigenous solution but pushing a donor solution—it’s what the donors want, what the international health community wants, but not necessarily what might be right for that particular country. Could you expand a bit on that? It seems that this is a problem throughout development. This is not unique to health by any means, but in this particular respect where it is so urgent and so crucial, if there are local solutions tailor-made for a particular environment, why is it that donors are ignoring or choosing to pursue something else?

FREEDMAN: I think it’s important to distinguish between technical solutions and whether an indigenous solution is the right solution when it comes to technical questions, like whether a particular drug works for something or whether a traditional birth attendant will be able to address a biological, a medical, physiological problem. That’s one kind of issue, you know, whether an indigenous solution or a nonindigenous solution is appropriate.

But another—I think what Geeta was talking about before, which I 100 percent agree with, is the difference between a way of thinking that’s about finding a formula that can be externally imposed in a way that gets you sort of quick measurable wins which kind of in a—it’s a little bit stereotyped, but very often donors are understandably looking for evidence that very quickly and in a way that can be carefully kind of formulaically described and replicated and scaled up everywhere, that you can get results, versus an approach that really puts a premium on problem solving, on building capacity, on developing—giving people the space to develop social institutions—all of those—that’s a—you know, a less clean, easily identified solution. But I think that anyone who looks carefully and hard at this problem, or really any global health problem, recognizes that that’s part of the ultimate solution. I mean, even if we find a magic vaccine for something, we still have to get it to people; we still have to give people the ability to pay for it or otherwise access it. So even with their so-called magic bullets, they’re never really magic bullets.

GUPTA: I just want to add to that that I can understand why it’s so attractive to want that magic bullet and the simple solution, you know, in the face of something as intractable as poverty and all of what it entails. It is an attractive thing to want. So it’s understandable. It’s just what’s frustrating is that after three decades of having tried—and I’m here referring not just to maternal mortality but a whole range of development and poverty eradication issues—you know, of three decades of experience with short-term solutions that we invested millions of dollars in and then didn’t give us the results we want, I think the world has now come to a point where it better recognize that if we’re going to meet those Millennium Development Goals that we have to invest in the long term; that we have to invest in capacity building, in the building of institutions, setting up systems—the building blocks that make for democratic societies that can then resolve these problems. And there is no shortcut to that. There can be interim—you know, we can identify particular models here and there that must be in place—emergency obstetric care is one for maternal mortality. But even that without some of the other things that need to be in place won’t work. So I think that that’s the important lesson from development overall.

FREEDMAN: I think we also really need to break this kind of myth that certain reports of isolated technical interventions are cheap, cost-effective, you know, and the way to go and that systemic solutions are only always very expensive, very long term, very hard to do. I think that if we looked at it differently we would see that systemic interventions, first of all, can be very cost effective; and, secondly, we know we can get very fast response actually with the right kinds of investment. There are a number of historical studies maternal mortality reduction—the cases that are always cited are Sri Lanka and Malaysia—whereby investing in health systems they were able to cut maternal mortality by 50 percent every seven to 10 years. And that is I think a—that is not a, you know, long-term, almost never see a solution.

We also know from our own work at AMDD that when we invest and properly support something like emergency obstetric care, we saw in our own programs many countries in the world that in three years we could more than double the number of complications treated in the facility. We could halve the case fatality rate in the facility. So it’s not as though you can’t get a solution that you can see. I mean, you can get impact. I think there’s a kind of myth that people just accept that certain kinds of technical solutions are cheap, good investments and certain kinds of systemic solutions are almost long and not cost effective. I think we need to break that.

COLEMAN: Let’s turn to the always controversial subject of family planning and contraception. Family planning and access to contraception clearly allow women to control their pregnancies better, space their pregnancies, have fewer pregnancies, which then leads to a lower number of deaths in childbirth. But it doesn’t always address that maternal mortality ratio as you were talking about earlier. Can we talk a little bit about the role of family planning in the whole maternal mortality issue and just giving us a context for understanding that and knowing how controversial it is in so many countries?

GUPTA: I wish it wasn’t controversial, because it’s a simple fact if women can prevent unwanted pregnancies. It’s not just that there’d be fewer incidence of pregnancy than can then result in maternal mortality; it’s also it reduces the number of unwanted pregnancies, because unwanted pregnancies often result in abortions, many of which, unfortunately, even in countries where this is legal, are going on under unsafe condition that then result in maternal mortality. You know, 13 percent of all global—on a global scale of maternal mortality is due to unsafe abortions. And in some settings that percentage can be as high as 50 percent of all maternal deaths are because of unsafe abortions.

So I would say the way to look at the contribution of family planning to maternal mortality is through the lens of unsafe abortions and to talk about how important contraception is to reducing unwanted pregnancies, and therefore avoiding at least some potential for unsafe abortions. The other piece of it is of course where it is legal to provide safe abortion services, so that women can actually access, because even in countries where it is legal it is provided in such a way that women don’t access it, or confidentiality is not maintained, or a whole host of issues around that that we need to address. But I think that’s a fact of life, and I regret that it’s become so politically controversial that now even family planning has become controversial because it shouldn’t be. It’s what helps prevent what we want to prevent.

FREEDMAN: And I know Geeta would also agree that family planning and access to the means to control your reproductive life is a fundamental, fundamental part of women’s human rights and of enabling women to become fully active parts of a society, to be the kind of—be part of the kind of society that will ensure accountability, even accountability in a health system, accountability from their government. It’s just I think a fundamental part of maternal health, of women’s human rights, and it’s the whole picture within which maternal mortality is really nestled, in addition to the very specific questions about the number of deaths, the number of pregnancies, deaths from complications of unsafe abortions.

COLEMAN: There is a fact sheet included—I think it’s out on the table when you came in. There’s some materials out there—articles that Dr. Rosenfield has written and a few other background materials. But there is a fact sheet out there. And if you look at it, on one side it has countries’ access to contraception and maternal mortality ratios. And it also has some facts on the other side. And you’ll note down at the bottom that out of a multi-billion dollar aid budget, over $9 billion, the United States spends a piddling amount—I think it’s around $10 million—on specifically on maternal health. Is it actually fair to—USAID officials I know have pushed back on me and said, Well, that’s not the right way to look at that number. That might be what is devoted specifically to maternal health. But based on the conversation that we’re having here, about how it really is an integrated problem that requires an integrated solution, you can look at the money that’s spent, say, on girls literacy as really a part of maternal health or on road building, so that women can access hospitals. I mean, is it fair to look at that number as but all that we do? And even if it isn’t, what ways should we be spending more money on this topic? Because even if you quadruple or quintuple or by a factor of 20 that number, it’s still tiny in terms of overall spending? Where should we be putting more money? You know, a marginal dollar of aid—what should it be going into to really help in maternal health and maternal mortality specifically?

FREEDMAN: I think maybe the answer is health systems. And when I say that I’m really talking about the system close to the community; not just community based, but basically a district level health system from community to a first referral level facility.

I think the kinds of numbers—I think the fundamental point is we can easily afford to do what’s required to be done. I mean, the millennium project has done a lot of projections; WHO has done a lot of projections. I think the number that WHO uses is something like we need an additional $9 billion per year to get something like 95 percent coverage of all the known effective interventions for maternal and newborn health. And so $9 billion a year.

Just for example, before I came I looked at some numbers. The world spends $40 billion a year on pet food. The world spends—what did I write down?—$35 billion a year on bottled water; $11 billion on ice cream. We can afford $9 billion for maternal and newborn mortality. In fact, maternal health—that number includes family planning—not family planning—antenatal care, you know, a whole range of maternal health interventions. So I think that’s really the key point. We can afford it. And by “we” I mean the world, and the U.S. is a big part of that of course. And the numbers that have been just projected as estimates by WHO, by the millennium project, are well under the 0.7 percent GDP target. We’re not talking about going way above where we were. That’s for rich countries to do development assistance.

There’s also the very important question of what percent of your budget—the countries where mortality is high—what percent of their budgets they devote to these issues. And that’s another scandal. So that’s the second part of this question I think that we can’t overlook—both sides.

GUPTA: Just to answer the very specific question about whether investments in education can be then counted as investments in maternal health, you know, I—I don’t think they either-or help. I think you need all of it. You need the investment in education, you need the investment in maternal health, and you cannot believe that the investments in education alone will take care of all of the services, facility-related things that need to happen in order to improve maternal health. It’s one of the ways, one of the ingredients of improving maternal health. It does give you that outcome in the long term—but only if services and facilities increase, that exist, that have the staffing and equipment and the skilled staff and so on that is needed. So it’s not an either-or, unfortunately.

I remember well walking down the hall with the new administrator of USAID once. He said to me, Tell me three things that I can do—just three things—can’t afford to do more than three things. And I said, if you can do three, you can do five. If you can do five, you can do seven. Where did you pick up this magical three from? (Laughter.) You know, so it’s just this mentality we have that somehow one or two things, if I can invest in I will be able to fix the problem. Unfortunately, all of life and all of development is much more complicated than that.

COLEMAN: Let’s take some questions from the audience. Could you please stand and identify yourself and wait for the microphone, and ask short and concise questions? We’ll start over here. Please wait for the mike.

Q My name is—(inaudible). I work in UNFPA-HQ, New York. I always like to ask—this is the age of—(inaudible)—support, this is the age of the Paris Declaration. Now when countries receive monies they usually receive them in full funds. How can we—you know, we have been thinking a lot about this—how can the U.S. for example convince or make a case even to the ministers of finance who say that, Hey, you know, let’s invest some of this food funds into MMR? And how could you do that? You know, given that the finance minister, for example, would say, But we would like to build a bridge. We would like to invest in economic growth. So, you know, there’s this tension here between investing in social factors and in economic growth, especially in sub-Saharan Africa.

GUPTA: I think the countries that have succeeded in terms of economic growth have actually proved that investments in human capital are what makes the difference.

QUESTIONER: But now—(off mike)—sub-Saharan Africa?

GUPTA: Provide that evidence. I would say provide that evidence to show that countries that have succeeded in making economic growth happen are countries that first made investments in human capital. And if your human capital is underresourced and dying, you are unlikely to meet your goal of economic growth. So I think we have failed to make that evidence available and widely known. But it is a fact, whether you look at the Asian tigers or you look at any of the emerging markets now that are doing well, it is those investments in human capital that have given us the biggest return. The infrastructure investments and so on are important, but in terms of long-term growth it’s the human capital investments that have made the difference. You know, when we talk that Malaysia and Sri Lanka have been the places that have reduced maternal mortality, you have to remember simultaneously in those very decades they were making huge investments in girls education. They were making sure that inequalities between women and men were addressed. And I think it’s all one package. It’s investment in human capital.

And you are right that it’s a difficult situation when finance ministers have to make these decisions. The finance ministers, if they understand economic growth, will understand investments in human capital.

COLEMAN: Let me just ask you specifically about India, your home country. India and China are always linked together on the world stage. In India today, a woman has a one in 48 chance of dying in childbirth. In China it’s one in 1,100—still high by developed country standards, but miles ahead of where India is. Does that argument resonate today in India that, look at China, it has invested much more in its human capital and India needs to catch up?

GUPTA: You know, the Indian prime minister fairly recently, actually in a public statement, talked about violence against women as an issue that needed to be addressed. I mean, I’m telling you that women (growth ?) is the issue, and when you begin to recognize that your reputation as a country on certain indices is somewhat poor, just when you’re trying to get into the big club, it matters. All these issues suddenly begin to matter. China has one much better in its delivery of health care overall. It’s a socialist communist economy that can make those things happen. They have a system that extends into the rural areas that makes it work. India has been less successful in doing that.

The inequalities in India in terms of access to health care are severe.

FREEDMAN: Can I make another point here? I think investment in health care is something that people want. You know, if you look at some of the studies that were done on this crisis, the studies that were done in 2000 by the World Bank, the set of participatory poverty assessments, that 60 of them were done called “Voice of the Poor,” the number one issue that people raised as being of concern to them was health. So to the extent that governments are also looking to do things that their people want and need, to the extent that people are able to voice those things and get responses from government, I think health will rise high in the agenda. And I think in India—and Geeta can correct me—I think this government’s national rural health mission is when it came into power the attempt to say rural health is—has to be high on the country’s agenda, and they tripled the health budget, as I understand, to address rural health. And I’m sure in part that was a political response to what people were demanding when they put that government into power.

GUPTA: And just as an interesting sidelight, as part of that national plan for the integrated rural health is a position at the community level for what’s called a “woman’s health activist.” It’s actually a government-based post in the plan, because they know it requires activism at the grass-root level to educate families about the importance of attending to important health issues and recognizing them. So I think there is a lot of progress and a lot of hope that things will improve moving forward.

COLEMAN: Betty?

Q Betty Marsham (ph). With the critical shortage of nursing faculty and nurses, who do you see delivering the education needed to do education for better health care for pregnant women and for neonatal? Who’s going to do this?

GUPTA: Brain drain.

FREEDMAN: Well, I mean I think we do have a serious issue in this country and in countries abroad with who is going to do it. And I think part of the answer is it won’t just be the people who traditionally do it. And I think—in fact, I think Allan can speak very eloquently to the role that, for example, obstetricians and specialists have in now really addressing mid-level providers and other level provides, and being part of the solution on this to really advancing training for them. But I think WHO has new global health—called the Global Health Work Force Alliance that has fast-track initiative that relates to training. I think it’s a huge issue that we’re going to have to really put resources into.

COLEMAN: In the back.

Q John Dreier—(inaudible). You referred to the intractability of the 500,000 number. How long has it been 500,000? And if I understood you to say 95 percent of it is in southern Africa and South Asia, that means it’s really about 500,000 in those two areas. And what has been the annual number of births over that period each year? What has it grown from over the last—if it’s intractable for 10 years, what is the number of births in year one, and what is the number of births in year 10?

FREEDMAN: I think that the first MMR estimates, and estimates of the number of deaths, maternal deaths, were done in 1995. I think they were 1990 numbers. I don’t know, some of my colleagues in the audience might be able to tell me if that’s right. I think they were 1990 numbers. I think that the numbers themselves came out in 1995, which is one of the problems in this field. You can’t measure these numbers until many years later. So that roughly 500,000 number—and they are very rough numbers—comes from around 1990. And it’s been approximately that each time there’s been global measures, which I think has been two or three times every five years I think they’ve tried to do these kinds of estimates.

The number of births—I have this millennium project report in front of me, and if I spend some time leafing through it I could come up with the number. I mean, it’s gone up, although the total fertility rate has definitely gone down. So I don’t know what the answer is, but the implication of your point—

QUESTIONER: (Off mike.)

FREEDMAN:—is that there is some success, even if the total number is staying the same. But the MMR also in many places hasn’t changed, and that’s unrelated. So the MMR, the maternal mortality ratio, the number of deaths per 100,000 live births, is kind of a measure of the safety of giving birth, has not changed in many places. Indeed, in many places it has gotten much worse, especially with HIV, malaria and other indirect causes.

So, yes, there have been some successes, and there are some very notable ones. I mean, parts of China have had great success, Honduras—

COLEMAN: (Off mike.)

FREEDMAN:—many parts of Latin America. It’s certainly true. This is not by any means a totally bleak picture.

Q Marlene Founder (ph), former television journalist. How do you deal with donor governments, like the United States for example right now, that oppose health systems that include abortion or even birth control systems in other countries? So that is an issue? Do you understand my question?

COLEMAN: I think we’re actually going to get into that in great detail in the second session, so can I ask if we hold that question until the second session?

Q Okay.

COLEMAN: And let’s not forget it, because it’s a very good one.

Back here.

Q I’m Lena Moussa (ph) from Women’s eNews. I’m curious about the success stories and what were the key ingredients that came together to make up the actual decrease of maternal mortality in like you said Honduras, Latin America, also in some parts of China? And, also, what do you predict will be the impact of the new Warren Buffett contribution to the Bill Gates and Melinda Gates Foundation? (Laughter.) I’m doing a story on it this week, so I want to get any opinions you have—

GUPTA: Everyone is doing a story on that this week. (Laughter.)

FREEDMAN: It is the story. I think one of the issues we haven’t really raised that goes to where countries have been successful that we haven’t talked about too much is I think countries that have had real success have really looked seriously at equity. They have really made an attempt to reach the people who are not automatically being reached without real attention to it. We see this in Malaysia, Sri Lanka, Honduras. In all of these countries really that have had success, they address equity. And the other thing is that they really invested in the system. They weren’t just looking for a magic bullet, you know, one drug. There are drugs that address one cause of maternal death.

The other thing, you could look at these different magic bullets, but the countries that have been very successful have addressed the health system where necessary. They changed their laws about who can delivery what care. Malaysia, for example, changed its laws about what nurses were allowed to do, because they recognized that if it was ever going to get appropriate maternal health care into rural areas it was going to have to rely on nurses. The country saw that, and it changed its laws, because it mattered that people get the care.

So I think this kind of political determination, a sense of urgency, a sense that women dying in childbirth is an avoidable scandal—all of those things have really been I think part of the success story in countries on every continent.

GUPTA: And I just want to underscore the political determination, because, as you can imagine in every country, if you try to change what a professional group can do, there is a heavy lobby from the professional group that previously had that task assigned to them to sort of oppose that action. It does require a political commitment to make it happen. And I just emphasize that, because we often forget that as an important ingredient in all of what we’re saying.

Q My name is Brook Beardsley (ph), and I’m wondering are there numbers on maternal morbidity like you have on mortality?

GUPTA: Not as good.

FREEDMAN: Yeah, I think morbidity is notoriously difficult to measure in any exact way. But among the estimates are for every death something like even 20 or 30 morbidities. There’s a famous article called—well, I guess it’s called “The Bottom of the Iceberg”—rather than meaning that mortality is the tip of a huge iceberg, and so for every death we measure there are something like—

GUPTA: Thirty to 40 I think.

FREEDMAN: Yeah, it’s a rough number. We should say one other point, which is that what happens to women at the time they deliver, give birth, also has huge impact on newborn mortality. So if we were able to address the safety of giving birth, it would not only have a massive effect on women’s deaths, but there are four million newborn deaths a year—a huge part of those are in the first day of life, a huge portion of them relate to the mother’s health and the care she gets at the time she gives birth. And that’s not even to mention another at least three to four million stillbirths. So all of those stillbirths and newborn deaths are also important parts of the impact of addressing maternal mortality and the safety of giving birth.

GUPTA: And that’s the biological link, but also a fortune link. So when a newborn loses his or her mother, that newborn has a reduced chance of survival because of the lack of the presence of the mother. And there’s an incredible study done years ago in Bangladesh that showed in the first five years there’s a 95 percent risk of that child dying because of the loss of the mother in poor households.

COLEMAN: That morbidity number is—I think I got to the nine million number of women affected.

Q Daniel Schwartz, Dynamica. To what degree are cultural institutions and norms, such as female genital mutilation and the like, a factor in this, and how do you see that changing?

GUPTA: I think the one cultural practice that I did want to talk about in connection with maternal mortality is child marriage, early marriage, and getting married too soon in societies where you’re expected to get pregnant immediately after you’re married is a big issue and thus contributes to some aspects of maternal mortality. So—and when I say “child marriage,” it’s not children getting married at 17; I’m talking about children getting married at 10, 12, 14. So as soon as they reach puberty, if they’re going to be pregnant, they are not biologically, physically ready to deliver a baby and are often then at very high risk of obstructed labor when—if emergency obstetric care is not available it can result in death. So it’s described as a cultural practice. In fact, it’s an economic solution in most countries to poverty, because if you have a number of children in the household and you can no longer feed them, it’s simple economic logic, you know, to get some of them married they’re out of the house at an earlier age, so your cost is reduced.

But as I was saying in an earlier conversation here today, we are discovering some very interesting facts about this that sort of blow the myth out of the water that it’s a cultural practice. It’s a little bit—when something is done for a long time a particular way, it’s difficult to change only because to be the pioneer involves a fear; you know, What if I’m the only one who waits to get my daughter married? Would I get a good husband for my daughter? Will they all be gone by then? It’s the mentality to be the pioneer that stops people from even acting upon what they consider to be the ideal age of marriage.

So what we’re discovering from research we’re doing is that most parents in poor communities where the age of marriage is—for example, average age of marriage is 14, will say they want their daughter to be married at 21. And the girls will say 24. And yet girls are getting married between 12 and 15. So why is that happening? And so very simple intervention where you relay those facts back to the community and get some families the support they need, the social support they need to assure them that if the girls don’t get married at 12 or 14 they can still be kept safe, they can still continue in school, have the transportation for school, get other life skills that they can learn. If you do it for just a few, there’s a diffusion effect where others then will take the step to delay marriage, because a few have done it and shown that there is no social cost involved.

So I just bring that up as a case where we often put things down as cultural, but they actually can sometimes be quite easily changed if there is movement from within.

FREEDMAN: If I can add, another similar practice that we often call cultural, yet I don’t think necessarily is, is whether women like to go to the hospital or not. Very often we go to places and they say, Okay, it’s cultural—women like to give birth at home, or women don’t like to come to the hospital. And they give cultural reasons for it. And indeed they may have—you know, in their articulation of it they may indeed articulate cultural reasons. On the other hand, where there are good services, good respectful, I would say, rights-based services, women come. Women want to use them. Women want their lives saved and their babies saved. And so very often I think the “cultural” label justification is one that people may articulate it that way—I don’t doubt that for a minute—but I think it’s not always kind of written in stone.

And your very specific question—I think there’s recent data in the last couple weeks even, that does correlate female genitalia cutting with maternal mortality. But I would say—

COLEMAN: With infant mortality.

FREEDMAN: I think also there’s—and maternal. But I think, at the same time, the proportion of all deaths that that can account for is very small. So it’s not truly the answer.

GUPTA: Just one last point on this cultural issue. I want to say that with everything related to gender equality - whenever issues are raised about improving women’s status—we get a lot of people who want to oppose it, saying to you, but that’s the cultural issue, it’s cultural imperialism to impose things from the top. Don’t ever buy that. (Laughter.) Okay? Because it’s—you know, the need for equality comes from within societies. It’s never imposed from the top. All we’re doing is helping it happen perhaps by providing some technical skills. And, you know, it’s been a long time. The people have been waiting for it. So it’s not—it gets talked in that way because people think of these things as cultural and then think, Well, we can’t do anything about that. That’s millions of years old. It just can’t be changed within a few years. And we’ve proved that to be wrong every single time.

Q I’m Bruce Schearer, Synergos Institute. You’ve done a great job in framing the issue, and I think especially in emphasizing the need for investment in basic health services in poor areas around the world. We know from the millennium project that that’s going to be about $40 to $50 per person a year, and we can get there if we double foreign aid from $80 billion to $160 or so billion a year. So I’d like you to help us frame the issue from the financial and political perspective as well. If the real question is how to get that money, do we need to get it from donor governments, do we need to get it from national governments? Can we depend on the Gateses and Save the Children and our private contributions from civil society, both domestically and in Europe, and for that matter emerging nations, economies? How do you frame the issue of the resources for us? Thanks.

FREEDMAN: I think we need to do both in the sense that we need to—those countries themselves need to develop a higher percent of their own budgets to health and to basic health services. I think the African countries have a target of 15 percent that they agreed to at a conference called the Abuja target—in which countries we need to increase ODA. I think that this is an issue that is fundamentally for governments. I think that private foundations can have a catalytic effect, can really help us come to new solutions and so on, but I think this is fundamentally a human rights issue that is fundamentally the obligation of governments to ensure that the issue is addressed. I think there are many ways the government can do it, but I think it’s fundamentally the responsibility of governments to ensure that people have access to basic health systems.

GUPTA: I would agree with that. I was going to say E, all of the above, because—you know, yes, Lynn is right, that it’s governments’ responsibility. But certainly a foundation like the Gates Foundation could help enormously to make it happen, to get the momentum going in a country—to prove the point to a government that it can be addressed, and here’s how.

There are ways in which private money can be used to make that happen. But, yes, the financial positions are essential, but again not enough. It’s not the only answer. You get the money, and then you’ve got to spend it right, and you’ve got to spend it on the right things. And I think those are also very important parts of that equation. But absolutely we need more money for this problem.

FREEDMAN: I think there’s also an argument to be made that through countries that benefit from globalization owe something back; that the brain drain of human—the so-called brain drain in human resources is a stark example of where basically the resources that poor countries have put into training their own health professional who at high, high rates end up migrating to rich countries and staffing our hospitals right here outside the doors of the Council on Foreign Relations. Poor countries are subsidizing rich countries. And when we have that kind of dynamic I think it really changes the way we have to think about the sort of—it’s official development assistance. It’s not just charity. There is something about fundamental justice that I think we need to begin to develop as part of our thinking about why countries need to help other countries.

Q Janet Walsh from Human Rights Watch. I’m interested to hear what you might say about the World Bank’s heavily-indebted poor countries initiative as kind of a successor to structural adjustment programs, and what tensions there might be between supporting the kind of initiatives you’re saying, and also recommending perhaps a system, health system changes that might undermine this. Thank you.

FREEDMAN: Well, I mean, I think that in principle the HIPC initiative certainly is meant to produce, through debt relief, money for the health sector. But I think a lot of—or at least the studies that I’ve seen that WHO has done, and they have done a few generations of studies, indicate that it’s disappointing what percent of that money or how much of that money actually finds its way into a real change in the health sector and so on. And I think there are—I mean, it’s a long conversation, but I think there are serious issues about the right hand and the left hand. And very often we’re making certain kinds of arguments about the role of government, about the failure of the market for certain kinds of health care; and then, on the other hand, we’re making other kinds of arguments about the importance of market-based solutions. So I think there is some incoherence. You know, whether it’s all—the HIPC initiative should be the focus for looking at that, I’m not sure. But I think there is very often a kind of fundamental incoherence between advice for the health sector and overall advice for health sector reform. And poor people are routinely the ones who bear the brunt of that, because the ultimate effect is inequalities, growing inequalities with essentially poor and marginalized populations—the ones who are shut out.

COLEMAN: Geeta, did you want to comment?

GUPTA: No.

Q Vincent McGee. As a civil libertarian I’m reluctant to raise the question, but has anyone talked about or studied the possibility of negative incentives against brain drain in the wealthy countries?

GUPTA: (Laughs.) As one who left my country and came here, I you know frankly believe that mobility across country lines is an extremely important thing to allow and to permit. I don’t think you can effectively put a halt to that. It’s the way the globe is now. We have this flat world, you know, where people are going to be international citizens and are going to belong to more than one, and sometimes multiple countries. I think there’s a wealth to be generated by that in terms of knowledge, cultural exchange, et cetera, that we shouldn’t leave out on.

But the brain drain issue definition that I like best is the one that Lynn talked about, where in some way if it is at a magnitude where the poverty in a country has been further deepened because of the drain out, and incentives are being provided for people to leave their countries to come to the developed world, then there has to be some system of what I call taxation, that nobody wants to use for political reasons, where you pay somehow for what you’re benefiting from, which is the subsidized educated labor force that you’re benefiting from in the North. So I think that’s—some kind of solution of that kind is better than trying to put a halt on negative incentives to individuals for leaving their countries and coming in search of employment elsewhere. But that’s just my personal view when I say it, biased based on my personal situation.

FREEDMAN: I think if I make an incentive you include things like—I think there are countries that are looking at—I forget what they call them—bonding schemes or something where if you get supported to go to medical school, you spend two years in a rural area. And there is some research and so on on those things.

But I agree that it’s a big human rights issue, and we shouldn’t forget that it’s in the context of everything else that’s happening in the world today on the movement of populations and Fortress Europe, and whether or not people are welcomed in countries that are not the countries of their birth. So I think on this issue we really need to look at the bigger world we live in and try to do balancing acts.

GUPTA: I also just want to say that the situation of India, recognize, is very different from the situation of many countries in sub-Saharan Africa.

I just want to make the point that it is—that the nonresident Indians who live elsewhere in the world have been a huge part of the growth that India is experiencing now. And I think that there is a certain—I had never traveled anywhere abroad before I came to the U.S. It was my second trip on a plane—21 years ago—and the first time ever I had been to any other country other than my own. And the way in which my horizons got expanded, and the way in which I began to see the world—I am the strongest advocate for people to work and live and study elsewhere. Come back if possible, obviously—you know, if you can go back and want to go back, that would be the best. But any mechanism that stops people from traveling out of their land and forcefully puts them in some kind of bondage where they have to return against their will, I think would just be detrimental.

COLEMAN: We are going to wrap up now. I think we’re out of time. And we’re going to move in—we have a short break and move into the next session, where we really focus on solutions. But, before we do that, if each of you could lead us into that by giving your own perspective on what you would do if you could direct international, regional, local governments in these efforts. What would you suggest?

GUPTA: If we were queen for a day? (Laughter.)

COLEMAN: Queen for a day. No, Melinda for a day. (Laughter.)

GUPTA: Go ahead, because I’ll add a little bit to yours, because we agree. We essentially agree. There’s no debate.

COLEMAN: I know. I know the answer to this question.

FREEDMAN: No, I mean, I think there needs to be a really fundamental shift in how we think about what the solutions are and the kind of solutions we need. And I think it’s from a kind of—we’re looking for the formula to get the impact to one that is a true kind of investment in the capacity of countries, of social institutions, of problem solving, that really genuinely builds societies and I think health systems and health are an absolutely essential part of that. So whether it’s from the technical question of maternal mortality reduction or the much bigger question of social justice, I think we need that kind of shift at all levels.

GUPTA: So, you know I agree 100 percent and would say the investments should be in health systems. I would just go up to the next level and say in order for that to happen and perhaps simultaneous to that happening, what we need is to increase the value of girls and women. And that can be done through societies. We need to increase their value to societies that—the perception of their value to societies. And that’s not just an attitudinal shift; it requires economic investments in order for that to happen, because people need to see the returns to that investment in order to be able to value girls. So for me it has made a dent in maternal mortality the day a mother doesn’t weep when a girl is born.

COLEMAN: Thank you. (Applause.)

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