As the stories start to emerge about the extra billions committed to supporting better family planning at today’s summit, attention should now turn to the problems faced by governments and health workers in fulfilling the laudable aims. A sober assessment reveals that, enthusiastic announcements aside, those involved in the family-planning summit would do well to heed the lessons learnt from wider efforts to improve maternal health. As a new ODI/Save the Children report shows, increasing access to and improving the uptake of family-planning methods will take rather more than distributing condoms. The increased resources announced today are welcome, but they will almost certainly not be sufficient.
This is the lesson emerging from attempts to reduce maternal mortality in the sub-Saharan African context. Delivering ‘better’ maternal health is not only about ensuring that there are sufficient numbers of skilled midwives or providing ambulances; neither is it only about making services freely available. Ensuring safe motherhood requires the delivery of a comprehensive package of goods and services supported by appropriate and context-sensitive institutions.
All the ingredients for reducing maternal mortality in Africa in particular are there. Simple interventions, such as ante- and post-natal care, the use of family planning and the attendance of skilled professionals during childbirth can prevent or manage the main causes of maternal death. Yet many sub-Saharan African countries have struggled to deliver improvements in maternal health.
Spend a few days at a rural health facility in Uganda or Malawi and the issues quickly become apparent. Understaffed, over-crowded facilities with frequently lacking basic medical equipment and drug supplies are all too common. Add this to an ignorance of modern health services and it is perhaps not difficult to understand why rural pregnant women might choose to stay at home. Even when pregnant women do make it to local health facilities, for example to give birth, the absence of petrol for ambulances can delay transfer to facilities capable of providing a potentially life-saving caesarean section in the event of complications.
Recent research by the Africa Power and Politics programme draws attention to the ways in which four countries have overcome, or not, the obstacles cited above, and suggests that maternal-health outcomes will only improve when these have been addressed. A recent comparative study of the rural provision of maternal health care in Malawi, Niger, Rwanda and Uganda reveals why maternal-health indicators in some of these countries have improved more quickly than others.
Firstly, recognising that it’s not just health policies that make the difference is critical. In Niger, the 2006 decision to abolish user fees for pregnant women led to a shortage of medicine. Paradoxically, a policy intended to improve women’s access to maternal healthcare arguably reduced it. On the contrary in Rwanda recent policy reforms have been had a positive impact; the widespread use of community-health workers has plugged human-resources shortages, and the introduction of the community-health insurance scheme has gone a long way to reducing financial obstacles to health care. The lesson to be learnt here is not whether user fees are good or bad but how they create different outcomes in different contexts at given times.
Secondly, it is very important whether performance disciplines are enforced and reporting mechanisms exist. In Uganda, the almost complete lack of supervision of local health workers appears to be one key explanation for the widespread absenteeism undermining the weak public-health system. In Rwanda, on the other hand, where regular and effective supervision and monitoring of health-sector staff exists at all levels, and where health providers and local authorities are required to submit regular reports, health-facility opening hours are more widely respected.
Finally the flexibility with which local problem-solving initiatives are supported and facilitated by government is a key component in a country’s ability to address obstacles to maternal-health delivery in specific local contexts. In Niger an effective local initiative which collected funds to pay for emergency ambulance-transfer costs by imposing a small charge on health-service users was banned because it contradicted health policy on user fees. This underlines the government’s inability to learn from and support locally coordinated solutions that could make a real difference to local women. On the contrary, Rwanda has been very responsive to local problem-solving initiatives that overcome key obstacles to the delivery of key services, including maternal health, and there has been a real attempt to include local participatory approaches and mechanisms which feed lesson-learning back into policy.
The results speak for themselves. According to the Demographic and Health Surveys, whilst Malawi has seen an important reduction in maternal mortality in recent years, it has only just recovered the losses made in the 1990s; and Niger and Uganda have seen almost no progress. On the other hand Rwanda has achieved a steep reduction in maternal mortality ratio from 1,071 per 100,000 live births in 2000 to 476 in 2010.
The Gates Foundation and the UK government should be applauded for their interest in family planning. Limiting family size and spacing children is a crucial element in reducing the risks of maternal mortality and a focus on the issue is long overdue. However, if it is to be successful, it needs to grapple with broader institutional issues.