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World Health Day - April 7, 1998
Invest in the Future: Support Safe Motherhood
© 1998 American Association for World Health
RESOURCE BOOKLET
American Association for World Health
1825 K Street, NW, Suite 1208 Washington, DC 20006
www.aawhworldhealth.org (202) 466-5883
Clinton Presidential Records
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visit the Clinton Presidential Library's Research Room.
"How is it possible, that in the midst of
Strengthening Maternal Health in
THE WORLD BANK
Bangladesh
unprecedented economic growth and technological
DID YOU
KNOW THAT
breaktbroughs, we have managed to allow alarming
In 1976, the Government of Bangladesh declared family planning a
top priority, and the World Bank joined the international communi-
numbers of young women to continue dying during
ty to help Bangladesh achieve its national family planning goals.
Each year almost
pregnancy and childbirth?"
While primarily focused on family planning, the first World Bank-
600,000 women die
financed project also included efforts to reduce maternal mortality
from complications of
James D. Wolfensohn, President, The World Bank
by training traditional birth attendants and providing maternal and
pregnancy and child-
child health kits. Later projects reflected the government's growing
birth.
commitment to maternal health, and included training of medical
In many developing
staff and expanding access to maternal health services as well as
countries, maternal
Gaggero/PAHO
C
omplications of pregnancy and childbirth constitute the
improving the nutrition of pregnant and lactating mothers. The gov-
deaths account for 25
leading cause of death and disability among women 15 to
ernment's 1997 Health and Population Sector Strategy, prepared with
to 33 percent of all
49 years of age, and 99 percent of these deaths occur in
Bank support, contributed to the design of a new health and popu-
deaths of women of
developing countries. The problem is particularly acute in Africa
lation project, which includes activities to improve antenatal, deliv-
and South Asia, where women's access to maternal health care and
ery, and post-natal care, and emphasizes developing basic and com-
childbearing age.
family planning is especially limited. Making motherhood safer is
prehensive emergency obstetric care in health centers and hospitals.
At least 40 percent of women who become pregnant each
fundamental to improving human welfare, reducing poverty and
year experience complications that require treatment
promoting economic development, which are the World Bank's
Partnerships Bring Progress to India's
from a trained provider, and one in 10 requires hospital-
overarching goals.
Urban Slums
ization.
The World Bank was a co-founder of the Safe Motherhood
More than one-half of all pregnant women in developing
Initiative, launched in 1987. The Initiative seeks to reduce illness
The World Bank has a large portfolio of safe motherhood-related
countries are anemic.
and death related to pregnancy by ensuring that women have the
projects in India. This includes nine population projects and sev-
The total cost of saving the lives of a mother or infant
best chance of having a safe pregnancy and delivery and a healthy
eral nutrition projects. A new, nation-wide reproductive and child
through antenatal, delivery and postnatal care is only US
baby. The ingredients necessary for making motherhood safer
health project has just been launched, and a woman and child
$230, while the benefits to families, communities, and
MAKING
include prenatal care, safe delivery, postnatal care, family planning,
development project focusing on nutrition will soon be underway.
countries is immeasurable.
and good nutrition. Also essential, is information to raise awareness
In the poorest and most disadvantaged neighborhoods of
By improving maternal health and nutrition and immedi-
among pregnant mothers and their families about the importance of
Hyderabad, the capital of Andhra Pradesh, a World Bank-financed
ate postnatal care we could prevent about 75 percent of
MOTHERHOOD
maternal health care and family planning services.
family welfare project is tackling the city's high maternal and child
The Bank's support for safe motherhood has increased substan-
mortality and fertility rates through an innovative partnership. The
perinatal deaths, more than 50 percent of infant deaths,
tially over the decade. In 1986, the Bank's overall lending program
women of the slums, NGOs, and government health staff have joined
and 99 percent of maternal deaths.
had less than 10 projects that included maternal health and family
forces to improve the quality and expand family health services in
SAFER
planning. Recognizing the magnitude of the problem, the Bank sig-
some of Hyderabad's poorest neighborhoods. Experience from ear-
nificantly expanded its efforts to make motherhood safer. Today, it
lier programs showed that a top-down, centralized approach to
For more information please contact:
is the largest single source of external assistance for safe mother-
delivering health care and family planning services was not effective.
hood, financing some 100 projects that address this issue. A few
The Municipal Corporation of Hyderabad turned to 24 NGOs to
Bank-financed projects are devoted mainly to safe motherhood.
assist in reaching out to the core slum areas not previously covered
However, most Bank-supported safe motherhood activities are part
by maternal and child health services. They educate communities
of broader health projects. These activities employ a variety of
about good maternal and child health practices and family planning,
Human Development Network
strategies, including multi-sectoral approaches and partnerships
train community link volunteers, organize group savings and com-
The World Bank
with other international agencies and non-governmental organiza-
munity development activities, and are expanding access to mater-
1818 H Street N.W., Washington, D.C. 20433
tions (NGOs).
nal and other health care services.
Delivering Safe Motherhood Services in
Reversing the Tide of Maternal Death in
Health Around the World," through grants to the World Health
Indonesia
Romania
Organization's Safe Motherhood Program; the "Technical
Consultation on Safe Motherhood: 10 years of lessons learned in
Indonesia launched its "village midwife" program in 1988 with the
World Bank support for Romania's health sector began in 1992 with
research and practice," held in Sri Lanka in October 1997; and
ambitious target of placing a midwife in every village by the year
the Health Rehabilitation Project. The project was designed to
maternal and reproductive health curriculum development by the
2000. The Bank supported training and deployment of these mid-
reverse a long decline in health indicators, including maternal
Pakistan College of Physicians and Surgeons. Together with the
wives, SO that 54,000 are now in place. The Bank has continued its
health. In partnership with the European Commission, UNICEF,
Canadian International Development Agency, the Bank supported
support. Most recently, a new Bank-financed project brings togeth-
WHO, and USAID, the project aimed to reduce maternal mortality by
the Safe Motherhood Demonstration Project (SMDP), imple-
er the powerful and successful community information apparatus of
improving reproductive health care services; rehabilitating rural
mented by The Population Council. This research demonstrated
the national family planning program and maternal health and other
dispensaries to expand women's access to health care; and provid-
the effectiveness of training midwives at the primary and referral
basic services provided by the Department of Health. Partners in
ing equipment needed to improve care for pregnancy complica-
levels in life saving skills in Ghana and Viet Nam and medical sec-
this project include both public and private sector agencies involved
tions, as well as for neonatal intensive care. The project provided
ond opinion for reducing unwarranted cesarean sections in
in maternal health activities. The project's objectives include creat-
training and equipment to upgrade 10 reproductive health referral
Ecuador.
ing individual, family and community-level demand; linking the
centers at university hospitals and 50 maternal/neonatal referral
demand with improved quality of services at the community and
units in both district and university hospitals. It also set up a net-
Future Directions
referral levels; developing sustainable systems to maintain the com-
work of 240 local family planning units and greatly increased the
munity midwife program; improving the technical skills of hospital
availability of contraceptives. During this period maternal mortali-
The Bank is fully commited to making motherhood safer. By
staff to manage obstetric emergencies; and investing in the future
ty dropped substantially.
working with countries to build a favorable policy environment
through an adolescent reproductive health education program.
and help target resources cost-effectively, many lives can be
Toward Safer Births in the Villages of
saved. Investments in safe motherhood will have an impact
Promoting Reproductive Health in the
Yemen
beyond improving women's status and the survival and health of
Philippines' Provinces
their families. They will also strengthen development capacity
Extending the Reach of Safe Motherhood
The World Bank is assisting Yemen in implementing its National
and promote sustainable economic growth.
in Zimbabwe
The Philippines, with World Bank assistance, is implementing a
Population Strategy through the Family Health Project, begun in
comprehensive, nation-wide reproductive health program, with
1993. The project is working to reduce unwanted fertility and
For Further Reading
The World Bank has supported Zimbabwe's health sector since
special emphasis in 41 provinces. Despite a well-developed health
maternal and infant mortality. These objectives are being met by
1987. This support has included efforts to improve the health sta-
system, more than 70 percent of women deliver their babies at
improving the access to and quality of maternal and child
Measham, Anthony and Richard Heaver, 1996, India's Family
tus of mothers and infants, increase family planning services, and
home. The Women's Health and Safe Motherhood Project address-
health/family planning services, initially in district hospitals and
Welfare Program, Washington, D.C.: World Bank
strengthen the government's capacity to plan and manage maternal
es the issues that have prevented women from seeking appropriate
then at the village level. Special focus is being placed on managing
Tinker, Anne and Marjorie Koblinsky, 1993, Making Motherbood
and child health and family planning services. The first project
care in the past and includes services essential for safe motherhood.
obstetric emergencies, blood banking, and operating theaters. The
Safe, World Bank Discussion Paper 202, Washington, D.C.:
trained health workers in family planning and midwifery, upgraded
Several key factors enabled the government to plan this program
project provides vehicles for patient referral, as well as fellowships
World Bank
health centers, and provided information and education about
effectively and are central to its success. First, a national survey was
to attract women to train as midwives. At the national level, the pro-
health and family planning. By project's end in 1994, 48 percent of
conducted to carefully assess women's health status. National-level
ject supports the training of health care workers by providing train-
World Bank, 1998, "Improving Reproductive Health: The Role of
couples were using contraceptives, more than 90 percent of all
policy dialogue culminated in acceptance of the 1994 International
ing facilities and technical assistance on curricula development for
the World Bank", Washington, D.C.: World Bank
women received antenatal care, and 70 percent had a facility-based
Conference on Population and Development's Program of Action,
primary health care and continuing education.
World Bank, 1998, Improving Women's Health in Pakistan and
assisted delivery. The ongoing project, which began in 1991, con-
positioning women's health and safe motherhood as one of six pri-
Saving Lives, Washington, D.C.: World Bank
tinues efforts to expand access to basic health, family planning and
ority health issues. Finally, reorganization of the Department of
The Safe Motherhood Grants Program
World Bank, 1996, Improving Women's Health in India,
nutrition services, especially for poorer families. It is also upgrad-
Health placed family planning, maternal and child health, and nutri-
Washington, D.C.: World Bank
ing the youth advisory services which include counseling and a
tion programs under one office and linked that office with hospital
Through its grants program, the World Bank supplements its lend-
World Bank, 1994, A New Agenda for Women's Health and
school-based family life education program.
administration, which is essential for ensuring care for obstetric
ing for safe motherhood by providing three to four small grants per
Nutrition, Washington, D.C.: World Bank
emergencies.
year for innovative activities. Examples include development of the
Mother-Baby Package and production of a wall chart on "Maternal
SAFE MOTHERHOOD ACTION MESSAGES
1.
Advance Safe Motherhood Through Human Rights. Defining maternal death as
a "social injustice" as well as a "health disadvantage" obligates governments to
address the causes of poor maternal health through their political, health and legal
systems. International treaties and national constitutions that address basic human
rights must be applied to safe motherhood issues in order to guarantee all women the
right to make free and informed decisions about their health, and access to quality
services before, during and after pregnancy and childbirth.
2.
Safe Motherhood Is a Vital Social and Economic Investment. All national
development plans and policies should include safe motherhood programs, in
recognition of the enormous cost of a woman's death and disability to health
systems, the labor force, communities and families. Additional resources should be
allocated for safe motherhood, and should be invested in the most cost-effective
interventions (in developing countries, basic maternal and newborn care can cost as
little as US$3 per person, per year).
3.
Empower Women, Ensure Choices. Governments, community leaders and
women's advocates need to address social, economic and cultural factors that limit
women's choices and decision-making abilities. Legal reform and community
mobilization is essential for empowering women to understand and articulate their
health needs, and to seek services with confidence and without delay.
4.
Delay Marriage and First Birth: Reproductive health information and services for
married and unmarried adolescents need to be: legally available, widely accessible,
and based on a true understanding of young people's lives. Community education
must encourage families and individuals to delay marriage and first births until
women are physically, emotionally and economically prepared to become mothers.
5.
Every Pregnancy Faces Risks: During pregnancy, any woman can develop
serious, life-threatening complications that require medical care. Because there is no
reliable way to predict which women will develop these complications, it is essential
that all pregnant women have access to high quality obstetric care throughout their
pregnancies, but especially during and immediately after childbirth when most
emergency complications arise. Antenatal care programs should not spend scarce
resources on screening mechanisms that attempt to predict a woman's risk of
developing complications.
6.
Ensure Skilled Attendance at Delivery. The single most critical intervention for
safe motherhood is to ensure that a health worker with midwifery skills is present at
every birth, and transportation is available in case of an emergency. A sufficient
number of health workers must be trained and provided with essential supplies and
equipment, especially in poor and rural communities.
7.
Improve Access to Quality Maternal Health Services. Health services should be
located as close as possible to where women live, and must offer affordable, high-
quality care. In order to meet required standards, health systems should have: an
adequate number of trained staff; a regular supply of drugs, equipment and supplies;
and functioning referral systems. Services should also be respectful of - and
responsive to - women's needs, preferences and cultural beliefs.
8.
Address Unwanted Pregnancy and Unsafe Abortion: Program planners should
aim to reduce the number of maternal deaths from unsafe abortion (which are the
most easily preventable maternal deaths) by ensuring that all safe motherhood
programs include: client-centered family planning services to prevent unwanted
pregnancy; contraceptive counseling for women who have had an induced abortion;
the use of appropriate technologies for women who experience abortion
complications; and, where abortion is not against the law, such abortion services
should be safe. In all cases, women should have access to quality services for the
management of complications arising from abortion.
9.
Measure Progress. Because it is difficult and costly to estimate maternal mortality
accurately, alternative ways of measuring the progress and impact of safe
motherhood programs must be used. Since maternal mortality is directly linked to
the coverage and quality of maternal health services, information on such indicators
as who cares for women during childbirth, where the delivery takes place, and the
quality of services at health facilities should be collected and analyzed.
10.
Power of Partnership: Reducing maternal mortality requires sustained, long-term
commitment and the inputs of a range of partners. Governments, non-governmental
organizations (including women's groups and family planning agencies),
international assistance agencies, donors, and others should share their diverse
strengths and work together to promote safe motherhood within countries and
communities and across national borders. Programs should be developed, evaluated
and improved with the involvement of clients, health providers and community
leaders. National plans and policies should put maternal health into its broad social
and economic context, and incorporate all groups and sectors that can support safe
motherhood.
"Each of the co-sponsors of the Safe Motherhood Initiative implements these
activities according to its specific mandate.
Safe Motherhood:
A Matter of Human Rights and Social Justice
For a woman to die from pregnancy and childbirth is a social injustice. Such deaths are rooted in women's powerless-
ness and unequal access to employment, finances, education, basic health care and other resources. These factors set
the stage for poor maternal health even before a pregnancy occurs, and make it worse once pregnancy and childbear-
ing have begun.
Making motherhood safer, therefore, requires more than good quality health services. Women must be empowered, and
their human rights - including their rights to good quality services and information during and after pregnancy and
childbirth - must be guaranteed.
The Powerlessness of Women¹
Millions of women in the developing world do not have
Percentage of Women Aged 15 to 49 With No Education³
the social and economic support they need to seek good
health and safe motherhood. Physical and psychological
100
83%
barriers include:
79%
80
- Limited exposure to information and new ideas: In many
60
48%
communities pregnancy is not seen as requiring special
38%
40
care, and women do not recognise danger signs during
pregnancy. Even if they are experiencing pain and suffer-
20
11%
10%
ing, they may have been raught that these conditions are
0
inevitable, and therefore do not seek medical care.
Burkina
Pakistan
Egypt
Uganda
Mexico
Thailand
Faso
- Limits on decision-making: In many developing countries,
men make the decisions about whether and when their
wives (or partners) will have sexual relations, use contra-
Health services that are insensitive to women's needs, or
ception or bear children. In some settings in Asia and
Africa, husbands, other family members or elders in the
staffed by rude health providers, do not offer women a real
community decide where a woman will give birth and
choice: In many cultures, women are reluctant to use
must give permission for her to be taken to a hospital.
health services because they feel threatened and humiliated
by health workers, or pressured to accept treatments that
- Limited access to education: In much of Africa and Asia,
conflict with their own values and customs.
75% of women age 25 and over are illiterate.² When girls
are denied schooling, as adults they tend to have poorer
HOW CAN EMPOWERING WOMEN MAKE MOTHERHOOD SAFER?'
health, larger families and their children face a higher risk
It enables women to:
of death.
speak out about their health needs and concerns.
- Limited resources: Poverty, cultural traditions and national
seck services with confidence and without delay.
laws restrict women's access to financial resources and
demand accountability from service providers, and from governments
for their policies.
inheritance in the developing world. Without money, they
cannot make independent choices about their health or
participate more fully in social and economic development.
seek necessary services.
Political Commitment to Safe Motherhood⁴
National policy-makers can establish a legal and political
- Ensuring that all women have the right to make decisions
basis for safe motherhood by defining maternal mortality
about their own health, free from coercion or violence,
as a "social injustice", as well as a "health disadvantage".
and based on full information.
By doing so, they will commit their governments to:
- Guaranteeing that all women have access to good quality
- Identifying the powerlessness that women face -
care before, during and after pregnancy and childbirth.
throughout their lives as well as during pregnancy - as
an injustice that countries must remedy through political,
health and legal systems.
Using International Human Rights to Advance Safe Motherhood
International human rights treaties can be used to advance
- Governments participating 111 the 1994 International
safe motherhood (see below). These documents, as well as
Conference on Population and Development and the 1995
most national constitutions, guarantee:
Fourth World Conference on Women agreed that women
and men have the right to decide it. when and how often
- The right to life, liberty and the security of the person.
These rights require governments to provide access to
to bear children, and should have access to reproductive
health services. They also pledged to cur the number of
appropriate health care, and to guarantee that citizens can
choose when and how often to bear children.
maternal deaths in half by the year 2000, and in half again
by 2015. Although these commitments are non-binding,
- Rights that relate to the foundation of families and of
the Committee on the Elimination of Discrimination
family life. These rights require governments to provide
Against Women, which monitors the Women's Convention
access to health care and other services women need to
(see below), is using them as standards for the 161 coun-
esrablish families and enjoy life within their families.
tries that signed the Convention.
- The right to health services (including information and
THE FOLLOWING INTERNATIONAL TREATIES PROVIDE FRAME-
education) and the benefits of scientific progress. These
WORKS THAT CAN BE USED TO ADVANCE SAFE MOTHERHOOD:
rights require governments 10 provide reproductive and
Convention on the Elimination of All Forms of Discrimination
sexual health care to women.
Against Women (the Women's Convention);
- The right to equality and nondiscrimination. These rights
International Covenant on Civil and Political Rights;
require governments to ensure that all women and girls
International Covenant on Economic, Social and Cultural Rights;
have access to services (such as education and health
Convention on the Rights of the Child;
care)-regardless of age, marital status, ethnicity or socio-
European Convention on Human Rights;
economic status.
American Convention on Human Rights: and
Recent international conferences and conventions set
African Charter on Human and Peoples' Rights.
explicit goals that support and protect women's reproduc-
Each is monitored by a group that develops performance standards
tive health needs.
for member countries and tracks compliance through periodic
reports provided by each country.
What Can Be Done
Governments must provide a framework for ensuring safe
- Allow women greater freedom to make their own health
motherhood by:
and life choices, encourage them to question unfair prac-
rices, and give them opportunities TO learn about their
- Reforming laws and policies that contribute to maternal
rights and health and to develop a feeling of entitlement
mortality (e.g. those that restrict women's access to
to medical care and other services.
reproductive health services and information) and imple-
menting laws and policies that protect women's health
- Help men understand their role in expanding choices for
(such as prohibitions against child marriage and female
women, and in ensuring responsible sexual and family life.
genital mutilation).
Everyone, including women's health advocates and
- Guaranteeing all women access to good quality mater-
donors, must:
nal health care and accurate information, and involving
- Hold governments accountable for effectively protecting
women in planning, implementing, monitoring and eval-
the human rights of their citizens by reporting any viola-
uating health programmes.
tions to constitutional courts and international
Community leaders, women's advocates, private organisa-
monitoring bodies.
tions and individuals must:
Sources:
1: S.J. Jejeebhoy, "Empower Women, Ensure Choices: Key (1) Enhancing Reproductive
International Planned Parenthood Federation (IPPF). and the Population Council; FCI
Health". Presentation at Safe Motherhood Technical Consultation in Sri Lanka, 18-23
serves as the secretariat.
October 1997.
These fact sheets have also been prepared in a more detailed version for technical andi-
2: The World's Women, 1970-1990, Trends and Statistics. United Nations, New York,
ences. For more information or copies of available materials, contact any IAG member, or
1991.
the Sex retarial #:
3: Women's Lives and Experiences: A Decade of Findings from the Demographic and
Health Signeys Program. Macro International, Calverton, MD. 1994
Family Care International
4: R.J. Cook, "Advancing Safe Motherhood Through Human Rights". Presentation at Safe
588 Broadway, Suite 503
New York, NY. 10012. USA
Motherhood Technical Consultation III Sri Lanka, 18-23 October 1997.
Tel: (212) 941-5300
Prepared by Family Care International (FCD and the Sape Motherhood Inter-Agency
Fax: (212) 941-5563
Group HAG). The TAC includes: the United Nations Children's From (UNICE). United
Foral:
Nations Population brand (UNTPA). World Back. World Health Organization AWHOR
W. size
Maternal Mortality
In many developing countries, complications of pregnancy and childbirth are the leading causes of death among
women of reproductive age. More than one woman dies every minute from such causes; 585,000 women die every
year.¹ Less than one percent of these deaths occur in developed countries, demonstrating that they could be
avoided if resources and services were available.¹
In addition to maternal death, women experience more than 50 million maternal health problems annually.²
As many as 300 million women - more than one-quarter of all adult women living in the developing world - -
currently suffer from short- or long-term illnesses and injuries related to pregnancy and childbirth.³
Maternal Death
Every woman can experience sudden and unexpected
Women risk death and disability each time they become
complications during pregnancy, childbirth, and just after
pregnant. Women in developing countries face these risks
delivery. Although high-quality, accessible health care
much more often, since they bear many more children than
has made maternal death a rare event in developed coun-
women in the developed world.¹
tries, these complications can often be fatal in the
developing world.
Women's Risk of Dying from Pregnancy and Childbirth
Region
Risk of Dying
All developing countries
1 in 48
Causes of Maternal Death Worldwide'
Africa
1 in 16
Indirect causes 20%
Asia
1 in 65
Severe bleeding 25%
Latin America & Caribbean
1 in 130
Other direct causes* 8%
All developed countries
1 in 1,800
Europe
1 in 1,400
Obstructed labour 8%
Infection 15%
North America
1 in 3,700
Eclampsia 12%
Unsafe abortion 13%
.
Other direct causes include: ectopic pregnancy. embolism. anaesthesia-related
Country-level differences are even more dramatic: for
:.
Indirect causes include: annemia. malaria, healt disease
example, in Ethiopia, 1 out of every 9 women die from
pregnancy-related complications, as compared to I in
8,700 in Switzerland.'
Deaths of Infants and Children
Each year, almost 8 million stillbirths and early neonatal
A study in Bangladesh found that a mother's death sharply
deaths (deaths within one week of birth) occur. These
increased the probability that her children. 11/1 to age 10,
deaths are caused largely by the same factors that lead to
will die within two years. This was especially true for her
maternal death and disability-women's poor health during
daughters.
pregnancy, inadequate care during delivery and lack of
newborn care."
Maternal Disabilities
At least 40% of women experience complications during
life-threatening problems.¹ Long-term complications can
pregnancy, childbirth and the period after delivery. An esti-
include chronic pain, impaired mobility, damage to the
mared 15% of these women develop potentially
reproductive system and infertility.
SAFE MOTHERHOOD FACT SHEET
Why Are Women Dying?
Most maternal complications and deaths occur either
- During pregnancy: The percentage of women who seek
during or shortly after delivery. Yet many women do
antenatal care at least once is 63% in Africa: 65% in Asia;
not receive the essential health care they need during
and 73% in Latin America and the Caribbean. At the
these periods:
country level, however, use of such services can be
extremely low. In Nepal, for example, only 15% of women
Coverage of Maternal Health Services'
receive antenatal care.⁷
Developed countries
100
97%
99%
Developing countries
- During childbirth: Each year, 60 million women give birth
90%
with the help of an untrained traditional birth attendant or
80
a family member, or with no help at all. Almost half of
65%
births in developing countries take place without the help
60
53%
of a skilled birth attendant (such as a doctor or midwife).7
40
30%
- After delivery: The majority of women in developing coun-
20
tries receive no postpartum care. In very poor countries
0
and regions, as few as 5% of women receive such care.⁷
Antenatal
Skilled Attendance
Postpartum
Care
at Delivery
Care
Why Do Women NOT Seek Services?
The factors that prevent women in developing countries
- multiple demands on women's time;
from getting the life-saving health care they need include:
- women's lack of decision-making power within the family.
-- distance from health services;
The poor quality of services, including poor treatment by
- cost (direct fees as well as the cost of transportation, drugs
health providers, also makes some women reluctant to use
and supplies);
services.
What Can Be Done
Ensure access to maternal health services. Most maternal
- postpartum family planning and basic neonatal care.
deaths, many health problems among women and chil-
Such care would cost about $3 per person per year in
dren, and the deaths of at least 1.5 million infants each
low-income countries. Basic maternal care alone can cost
year could be prevented through:
as little as $2 per person.*
- routine maternal care for all pregnancies, including a
Improve women's status and raise awareness about the
skilled attendant (midwife or doctor) at birth:
consequences of poor maternal health. Families and com-
- emergency treatment of complications during pregnancy,
munities must encourage and enable women to receive
delivery and after birth; and
proper care during pregnancy and delivery.
Sources:
I: "Revised 1990 Estimates of Maternal Mortality: A New Approach by WHO and UNICEF".
S: "Mother-Baby Package Costing Spreadsheet" (unpublished), World Health Organization,
World Health Organization, Geneva, 1996.
Geneva, 1997.
2: "Healthy Pregnancy and Childbearing." in Reproductive Health in Developing Countries:
Prepared by Family Care International (FCI) and the Safe Motherbood Inter-Agency Group
Expanding Dimensions. Building Solutions. A.O. Tsui, 1. N. Wasserheit. and J.G. Haaga, eds.
(IAG). The IAG includes: the United Nations Children's Froud (UNICEF). United Nations
Washington, DC, National Academy Press. 1997.
Population Fund (UNFPA). World Bank. World Health Organization (WHO). International
3: The Progress of Nations UNICEF New York, 1996.
Planned Parentbo Federation (IPPF). and the Population Comeil: FCI serves as the secretariat.
4: "Coverage of Maternal Care: A Lasting of Available Information, Fourth Edition". World
These fact sheets have also been prepared in more detailed versions for technical audiences. For
Health Organization, Geneva, 1997.
more information or copies of available materials. contact any IAG member. or the secretariat at:
5: M.A. Strong, "The Health of Adults in the Developing World: The View from Bangladesh",
Family Care International
Health Transation Review. 2(2):215-24, 1992.
588 Broadway, Suite 503
New York, NY. 10012, USA
6: W. Graham, "A Question of Survival? A Review of Safe Motherhood". Ministry of Health,
Tel: (212) 941-5300
Kenya, 1997.
Fax: (212) 941-5563
7: "Coverage of Maternal Care: A Listing of Available Information, Fourth Edition". World
Email: [email protected]
Health Organization, Geneva, 1997.
Web site address: uwusafemotherhood.org
1998
Maternal
Health:
A
ana
Economic
One-quarter of all adult women living in the developing world today suffer from some kind of illness or injury
related to pregnancy and childbirth. Each year, maternal health complications are responsible for the deaths of
585,000 women, and contribute to the deaths of at least 1.5 million infants in the first week of life, and 1.4 million
stillborn infants.¹ The social and economic cost of these disabilities and deaths - to families, communities, the
labour force and countries - is enormous.
The financial cost of basic maternal and newborn health services that could prevent these problems is, on aver-
age, only US$3 per person per year in developing countries; the cost of maternal health services alone can be as
little as $2 per person.² The total cost of saving the life of a mother or infant is approximately $230.
Why Focus on Maternal Health?
In developing countries, pregnancy and childbirth are the
Leading Causes of the Burden of Disease
leading causes of death, disease and disability among
20%
in Women Aged 15-44
18.0%
18%
in the Developing World, 1990'
women of reproductive age. They account for at least 18%
16%
of the burden of disease in this age group - more than any
14%
12%
other single health problem.³
10%
8.9%
8%
Maternal health interventions are among the most cost-
6.6%
7.0%
5.8%
6%
effective investments in health.
4%
3.2%
2.5%
2.5%
2%
0%
Respiratory
Annemia
Self
Depressive
HIV
Tuberculosis
STD
Maternal
infection
inflicted
disorders
causes
injuries
The Toll on Children
At least 30 to 40% of infant deaths are the result of poor
Child Deaths When a Parent Dies, per 1,000'
care during pregnancy and delivery. These deaths could be
Sons
avoided with improved maternal health, adequate nutrition
Daughters
200
190
and health care during pregnancy, and appropriate care
during childbirth."
150
Poor maternal health and nutrition contributes to low birth
100
80
weight in 20 million babies each year - almost 20% of all
55
births. These babies die more often than babies of normal
50
41
28
31
weight, and are at greater risk for infection, malnutrition
and long term disabilities, including visual and hearing
0
No parent dies
Father dies
Mother dies
impairments, learning disabilities and mental retardation.⁵
Motherless children are likely to get less health care and
education as they grow up. A study in Bangladesh found
that when a mother dies, her children - especially daugh-
ters - are much more likely to die than children whose
parents are both alive."
The Economic Cost
Women account for 70% of the 1.3 billion people who live
At least 60% of pregnant women in the developing world
in absolute poverty." When women cannot work because of
are anaemic, which reduces their energy - and can depress
health problems, the loss of their income, as well as the costs
their incomes.
of treatment, can drive them and their families into debt.
Studies in Sri Lanka and China found that anaemia
In India, a study found that disability reduced the produc-
reduced productivity among women tea plantation and
tivity of the female labour force by about 20%.8
SAFE MOTHERHOOD FACT SHEET
impact of iron supplements."
clothing for young children. When a household is headed
by a woman - which is the case for at least 20% of
When women cannot work the consequences can be espe-
households in Latin America and Africa - her poor health
cially severe for children. Women are more likely than men
can cause severe problems for the family."
to spend their own income on improving family welfare
Benefits for Governments and Health Systems
Prevention and early treatment are cost-effective. Millions of
Good maternal health services can strengthen the entire
premature deaths, illnesses and injuries can be avoided by
health system. A health facility that is equipped to provide
helping women prevent unwanted pregnancy and get prompt
essential obstetric care - such as blood transfusions,
treatment for reproductive health problems. These steps also
anaesthesia and surgery - can also treat accidents, trauma
help governments avoid the higher costs of treating serious,
and other medical emergencies for the community.
undetected health conditions, and the costs of providing
Building women's trust promotes preventive care. Women
health care and social services for women with long-term
who receive good care during pregnancy and childbirth are
disabilities, and for their families in case of their deaths.
more likely to seek services for children's health, family
planning and other health problems, including treatment of
sexually transmitted diseases.¹
What Can Be Done
Governments, non-governmental organisations, interna-
- Ensure that every woman has access to a continuum of
tional agencies and other funders must make a concerted
good-quality safe motherbood services offered at the
effort to:
community level, in health centres and in district and
regional hospitals.
- Acknowledge the social and economic benefits of good
maternal health, and include efforts to ensure maternal
health in all national policies and plans.
- Allocate resources to make maternal health services
available, especially in poor and rural areas. Existing
health care resources can be used to support the most
cost-effective interventions.
Sources:
1: A. Tinker, "Sate Motherhood as an Economic and Social Investment". Presentation at Safe
9: A New Agenda for Women's Health and Nutrition. World Bank, Washington, DC. 1994.
Motherhood Technical Consultation in Sri Lanka, 18-23 Derober 1997.
10: United Nations Department of International Economic and Social Affairs, The World's
2: "Mother-Baby Package Costing Spreadsheet" (unpublished). World Health Organization,
Women: Trends and Statistics United Nations, New York. 1991.
Geneva, 1997.
Prepared by Family Care International (FCI) and the Safe Motherlood Inter-Agency Group
3: World Development Report 1993: Investing in Health. World Bank. Washington, DC, 1993.
(TAG). The IAG includes: the United Nations Children's Frond (UNICEF). United Nations
4: "Perinatal Mortality: A Lisung of Available Information". World Health Organization,
Population Friend (UNI-PA). World Bank. World Health Organization (WHO). International
Geneva. 1996.
Planned Parentbood Federation (IPPF). and the Population Council: FCI serves as the secretariat.
5:C Bellamy, The State of the World's Children 1998. UNICEF New York, 1998.
These fact sheets have also been prepared III more detailed versions for technical audiences. For
more information or copies of available materials. commet any IAG member, of the secretariat at:
6: M.A. Strong, "The Health of Adults in the Developing World: The View from Bangladesh".
Health Transition Review 2(2):215-24. 1992.
Family Care International
588 Broadway, Suite 503
7: Human Development Report 1995. United Nations Development Programme, New York,
New York. NY. 10012. USA
1995
Tel: (212) 941-5300
S: M. Chatteriee, Indian Women: Their Health and Productivity. World Bank Discussion Paper
Fax: (212)941-5563
109. Washington, DC, 1991.
Email: [email protected]
Web site address: www.safemotherhood.org
1998
is
The Safe Motherhood Initiative
When the Safe Motherhood Initiative was launched in 1987, death from the complications of pregnancy and child-
birth was a little-known, seriously neglected problem. Ten years later, preventing these deaths is an international
priority, and many countries have made significant progress in expanding and improving maternal health ser-
vices. The global Initiative has become a unique partnership of governments, donors, technical agencies,
non-governmental organisations and women's health advocates in more than 100 countries. These partners are
now working to protect the health and lives of women, especially during pregnancy and childbirth.
What We Know
Complications of pregnancy and childbirth are the leading
hospitals located as close as possible to where women live,
causes of disability and death among women between the
and must be linked by an emergency referral and transport
ages of 15 and 49 in developing countries.¹
system.
Every woman is at risk. During pregnancy, any woman can
Safe motherhood strategies must be comprehensive. Even
experience life-threatening and unpredictable complications
when good quality health services are available, social, eco-
that require immediate medical care.
nomic and cultural limitations can prevent women from
using these services. Safe motherhood programmes empha-
In order to reduce deaths, good-quality maternal health
sise the need for action on these root causes, and also on
services must be readily available - and must be used -
other reproductive health problems, including unwanted
especially during and immediately after childbirth. Services
pregnancy and sexually transmitted diseases.
should be provided by trained health workers, clinics and
The Next Ten Years
In the last several years, safe motherhood has been
Changes in Attendance at Delivery, 1985-1996
embraced by governments all over the world. They have
Trained attendant 1985
100
initiated programmes to reduce maternal death, improve
Skilled attendant 1996
98% 99%
reproductive health services, and protect and promote
80
75%
women's health and well-being, especially during preg-
64%
60
nancy and childbirth.
52%
53%
49%
42%
40
34%
34%
To help governments and private organisations meet their
maternal health goals, safe motherhood partners from
20
around the world met in October 1997 to identify the most
0
efficient and cost-effective ways to improve maternal
Africa
Oceania
Asia
Latin America Developed
& Caribbean Regions
health. Participants discussed research results, new tech-
liamed attendant includes indwife Inctor and named inditional birth attendant
Stilled attendant Includes only doctor and midwite
nologies, model programmes and lessons learned during the
Initiative's first decade. The meeting identified ten essential
action messages for improving maternal health (fact sheets
on these messages are available for both general and tech-
nical audiences), and led to an agreement on the key health
services that should be available to make motherhood safer.
This package of services is described in the box on the fol-
lowing page.
SAFE MOTHERHOOD FACT SHEET
A comprehensive package of services for safe motherhood
- Throughout the Reproductive Life Span: Abortion-
should include:
related care.
- During Pregnancy: Antenatal care and counselling.
High-quality services for treating and managing compli-
cations of unsafe abortion should be available through
During pregnancy, health workers should: educate
all health systems. Services require: staff who are trained
women about how to stay healthy during pregnancy;
help women and families prepare for childbirth; and
and authorised to treat complications; appropriate equip-
ment; protocols for care: and effective referral networks.
raise awareness about possible pregnancy complications
Women with abortion complications should also have
and how to recognise and treat them. Health workers
should also identify and manage any complications early
access to other reproductive health services, including
and improve women's reproductive health and well-being
family planning.
through preventive measures (iron supplements, tetanus
Where abortion is not against the law, safe services for
immunisation) and by detecting and treating existing
pregnancy termination and compassionate counselling
problems (such as sexually transmitted diseases).
should be available.* Health workers must be informed
about the legal status of abortion and protocols for pro-
- During Childbirth: Skilled care during labour and delivery.
viding it. Appropriate technologies, including new
During childbirth, every woman should be helped by a
methods such as non-surgical abortion, should be avail-
health professional who can manage a normal delivery as
able where feasible.
well as derect and manage complications such as haemor-
rhage, shock and infection. Skilled attendants should have
- During Adolescence: Reproductive health education
access to a functioning emergency and transport system so
and services*.
that they can refer women to an appropriate health facility
All young people should have information on sexuality,
for higher level medical care (such as Caesarean delivery or
reproduction, contraception, decision-making skills and
blood transfusion) when necessary.
gender relations in order to help them make informed
decisions about sexuality and to negotiate abstinence or
- After Delivery: Postpartum care.
Following childbirth, women should be seen by a health
safer sex. Sensitive, respectful and confidential reproduc-
tive health counselling and services for married and
worker, preferably within three days, so that any prob-
lems (such as infection) can be detected and managed
unmarried adolescents should emphasise the prevention
of unwanted pregnancy, unsafe abortion and sexually
early. An additional postpartum visit within the first six
transmitted diseases (STDs).
weeks after delivery enables health workers to make sure
that the mother and baby are doing well, to provide
- For Women and Families: Community education.
advice and support for breastfeeding and to offer family
Key health topics for women and their families include
planning information and services.
how to prevent unwanted pregnancy and avoid unsafe
- Before and After Pregnancy: Family planning.
abortion; how to recognise complications of pregnancy,
childbirth and unsafe abortion and where to seek
Family planning counselling and services should be avail-
able to all couples and individuals, including adolescents
treatment; and the dangers of certain traditional prac-
tices during pregnancy and childbirth. Education is also
and unmarried women. Family planning services should
needed for decision-makers - from husbands to com-
offer complete information and counselling as well as a
wide choice of modern contraceptives, including emer-
munity leaders to national policy-makers - to promote
gency contraception, and should be part of a
safe motherhood and improvements in women's health
and status.
comprehensive programme that addresses other sexual
and reproductive health needs.
*Each co-sponsor of the Safe Motherhood Initiative implements these
activities according to its specific mandate.
Sources:
I: World Development Report 1993: Investing in Health. World Bank, Washington, DC,
World Health Organization
1993.
Maternal and Newborn Health/Safe Motherhood Programme
2: "Coverage of Maternal Care: A Listing of Available Information, Fourth Edition".
Division of Reproductive Health (Technical Support)
World Health Organization, Geneva, 1997.
1211 Geneva 27 Switzerland
The Safe Motherhood Co-sponsors
International Planned Parenthood Federation (PPF)
Assistant Secretary General
The Safe Motherhood Initiative is led by a unique alliance of co-sponsoring agencies who
Sexual and Reproductive Health Technical Support Group
work together to raise awareness, set priorities, stimulate research, mobilise resources, pro-
Regent's College. Inner Circle, Regent's Park
vide technical assistance and share information. Each of these agencies implements safe
London NW1 4NS England
motherhood activities according to as specific mandate. The co-sponsors include:
The Population Council
United Nations Children's Fund (UNICEF)
International Programs Division
Division of Communication
One Dag Hammarskjold Plaza
SUN Plaza
New York, New York 10017 USA
New York. New York 10017 USA
For further information and copies of available materials, including additional fact sheets.
United Nations Population Fund (UNFPA)
please contact the Safe Motherbood Initiative secretariat:
Technical Branch, Technical and Policy Division
220 East 42nd Street
Family Care International
New York, New York 10017 USA
588 Broadway, Suite 503
New York. New York 10012 USA
The World Bank
Tel: 212 941-5300 Fax: 212 941-5563
Health, Nutrition and Population
Email: [email protected]
Human Development Network
Web site address: www.safemotherbood.ong
1818 H Street, N.W.
1998
Washington D.C. 20433 USA
O
The "Year of Safe Motherhood"
Safe Motherhood is a global effort to increase maternal safety and
reduce the number of deaths and illnesses associated with
pregnancy and childbirth
Women need not die while giving life to future generations.
Every minute of every day. somewhere in the world and most often in a developing nation, a woman
dies from complications related to pregnancy or childbirth. Her death is more than a personal
tragedy. although that alone would merit our most serious concern. In addition, her death represents
an enormous cost to her nation. her community and her family. Any social and economic investment
that has been made in her life is lost. Her family loses her love. her nurturing and her productivity
inside and outside the home. Half of all infant deaths can be attributed to poor maternal health.
Moreover. the child that survives a mother's death is up to ten times more likely to die within two
years than a child with two living parents."
The greatest tragedy is that these approximately 600.000 maternal deaths and over 50 million cases of
morbidity that occur each year are largely preventable. A decade of research has proven that
surprisingly small and affordable measures can significantly reduce the health risks that women face
when they become pregnant.
In 1987 a coalition of the world's leaders in maternal and child health. the United Nations Population
Fund (UNFPA). the United Nations Children's Fund (UNICEF). the World Health Organization
(WHO). the World Bank. the International Planned Parenthood Federation (IPPF) and the Population
Council. joined forces and developed an Inter-Agency Task Force on Safe Motherhood to assess this
problem and recommend solutions.
Now it is time to act upon what has been learned over the past ten years of research and model
projects. before one more woman loses her life needlessly.
To achieve this goal. World Health Day. 7 April 1998 will kick-off a year-long series of activities to
promote Safe Motherhood.
On that day a call to action will be issued to governments. business leaders. policy makers. and
citizens of every country of the world. The call to action consists of four simple messages:
I. International aid agencies are urged to provide overseas assistance to programs that promote
maternal care as an essential component of reproductive health services.
2. Governments or developing countries are urged to reduce maternal mortality and morbidity by
developing and implementing health. nutrition and education programs that promote the health of
pregnant women and their infants.
3. Corporations around the world are urged to encourage governments and private organizations in
the countries where they do business to provide funds and develop programs that foster safe
motherhood. and to support safe motherhood among their employees and customers.
1. Women. men and families everywhere are urged to demand and seek quality prenatal and
obstetric care to ensure that no woman dies or suffers long-term complications from childbirth.
O
www.safemotherhood.org
Safe
Motherhood
what's on the site?
www.safemotherhood.org aims to provide visitors with comprehensive and up
to date information on the Year of Safe Motherhood and the issue of maternal
mortality.
Inter-Agency Group
for Safe Motherbood
www.safemotherhood.org will be updated throughout the year as new stories,
UNFPA
developments, and statistics emerge.
UNICEF
WHO
WORLD BANK
Main Features
IPPF
POPULATION COUNCIL
П What is safe motherhood?
An overview of the principles and components vital to ensuring safe and
healthy pregnancies
П Introduction
An introduction to the Year of Safe Motherhood, including aims and objectives
П Principles of Safe Motherhood
Ten Safe Motherhood action messages
П Facts & Figures
*
Data presenting global maternal health issues and causes of maternal
death in graph, map and table format
П World Health Day
The Agenda for events surrounding World Health Day - 7th April 1998
П Responsible Agencies
The members of the organisations behind the Safe Motherhood Initiative
and links to their websites
Chairing Agency:
IPPF
Regent's College, Regent's Park
Forthcoming attractions
London NWI 4NS. UK
Telephone: 44 171 487 7864
Fax: 44 171 487 7865
П Safe Motherhood Success Stories
email: [email protected]
Case studies of successful programmes to help pregnant women around the
world
Secretariat:
Family Care International
П Visitors Bulletin Board
588 Broadway, Suite 503
Comments. questions and opinions from visitors on safe motherhood issues
New York, NY 10012 USA
Telephone: 212 941 5300
Fax: 212 941 5563
email: [email protected]
O
Safe
Motherhood
Inter-Agency Group
for Safe Motherbood
Corporate Initiative for Safe Motherhood
UNFPA
UNICEF
Statement of Principles
WHO
WORLD BANK
Motherhood 1998
IPPF
POPULATION COUNCIL
Every day at least 1,600 women die from the complications of pregnancy and
childbirth. The remarkable advances in other areas of public health worldwide
have not been matched by improved survival for childbearing women. The same
factors that contribute to maternal illness and death also lead - each year - to
as many as eight million stillbirth and infant deaths within the first week of life. In
the developing world. a mother's death leaves her children more vulnerable to
illness and death.
The business leaders who have created the Corporate Initiative for Safe Motherhood
recognize these principles:
Motherhood represents an unequivocal commitment to the future of humankind.
As business leaders, we can have a vital role in educating our employees about the
simple measures that can prevent needless deaths and injury related to childbirth.
Our positions of leadership give us an opportunity to raise awareness of Safe
Motherhood among our business peers and within the communities in which we
conduct our business.
Chairing Agency:
We recognize the importance of inter-sectoral partnership in addressing the
IPPF
complexity of improving the health of childbearing women and their children.
Regent's College, Regent's Park
London NWI 4NS. UK
Telephone: 44 171 487 7864
Fax: 44 171 487 7865
email: [email protected]
Secretariat:
Family Care International
588 Broadway, Suite 503
New York, NY 10012 USA
Telephone: 212 941 5300
Fax: 212 941 5563
email: [email protected]
O
Safe
Motherhood
SAFE MOTHERHOOD ACTION MESSAGES
1.
Advance Safe Motherhood Through Human Rights. Defining maternal
death as a "social injustice" as well as a "health disadvantage" obligates
governments to address the causes of poor maternal health through their
political. health and legal systems. International treaties and national
Inter-Agency Group
for Safe Motherhood
constitutions that address basic human rights must be applied to safe
UNFPA
motherhood issues in order to guarantee all women the right to make free and
UNICEF
informed decisions about their health, and access to quality services before,
WHO
during and after pregnancy and childbirth.
WORLD BANK
2.
Safe Motherhood Is a Vital Social and Economic Investment. All national
IPPF
POPULATION COUNCIL
development plans and policies should include safe motherhood programs,
in recognition of the enormous cost of a woman's death and disability to
health systems, the labor force. communities and families. Additional
resources should be allocated for safe motherhood. and should be invested in
the most cost-effective interventions (in developing countries, basic maternal
and newborn care can cost as little as US$3 per person, per year).
3.
Empower Women, Ensure Choices. Governments. community leaders and
women's advocates need to address social. economic and cultural factors that
limit women's choices and decision-making abilities. Legal reform and
community mobilization is essential for empowering women to understand
and articulate their health needs. and to seek services with confidence and
without delay.
4.
Delay Marriage and First Birth: Reproductive health information and
services for married and unmarried adolescents need to be: legally available,
widely accessible, and based on a true understanding of young people's lives.
Community education must encourage families and individuals to delay
marriage and first births until women are physically. emotionally and
economically prepared to become mothers.
5.
Chairing Agency:
Every Pregnancy Faces Risks: During pregnancy. any woman can develop
IPPF
serious. life-threatening complications that require medical care. Because
Regent's College. Regent's Park
there is no reliable way to predict which women will develop these
London NW1 +NS. UK
complications, it is essential that all pregnant women have access to high
Telephone: 14 171 487 7364
quality obstetric care throughout their pregnancies. but especially during and
Fax: 14 171 487 7865
immediately after childbirth when most emergency complications arise.
email: [email protected]
Antenatal care programs should not spend scarce resources on screening
mechanisms that attempt to predict a woman's risk of developing
Secretariat:
complications.
Family Care International
588 Broadway, Suice 503
New York. NY 10012 USA
Telephone: 212 941 5300
Fax: 212 941 5563
email: [email protected]
6.
Ensure Skilled Attendance at Delivery. The single most critical intervention for
safe motherhood is to ensure that a health worker with midwifery skills is present at
every birth, and transportation is available in case of an emergency. A sufficient
number of health workers must be trained and provided with essential supplies and
equipment, especially in poor and rural communities.
7.
Improve Access to Quality Maternal Health Services. Health services should be
located as close as possible to where women live, and must offer affordable, high-
quality care. In order to meet required standards. health systems should have: an
adequate number of trained staff; a regular supply of drugs. equipment and supplies;
and functioning referral systems. Services should also be respectful of - and
responsive to - women's needs, preferences and cultural beliefs.
8.
Address Unwanted Pregnancy and Unsafe Abortion: Program planners should
aim to reduce the number of maternal deaths from unsafe abortion (which are the
most easily preventable maternal deaths) by ensuring that all safe motherhood
programs include: client-centered family planning services to prevent unwanted
pregnancy: contraceptive counseling for women who have had an induced abortion;
the use of appropriate technologies for women who experience abortion
complications: and. where abortion is not against the law. such abortion services
should be safe'. In all cases. women should have access to quality services for the
management of complications arising from abortion.
9.
Measure Progress. Because it is difficult and costly to estimate maternal mortality
accurately, alternative ways of measuring the progress and impact of safe
motherhood programs must be used. Since maternal mortality is directly linked to
the coverage and quality of maternal health services. information on such indicators
as who cares for women during childbirth. where the delivery takes place, and the
quality of services at health facilities should be collected and analyzed.
10.
Power of Partnership: Reducing maternal mortality requires sustained, long-term
commitment and the inputs of a range of partners. Governments. non-governmental
organizations (including women's groups and family planning agencies),
international assistance agencies, donors. and others should share their diverse
strengths and work together to promote safe motherhood within countries and
communities and across national borders. Programs should be developed. evaluated
and improved with the involvement of clients. health providers and community
leaders. National plans and policies should put maternal health into its broad social
and economic context, and incorporate all groups and sectors that can support safe
motherhood.
Each of the co-sponsors of the Safe Motherhood Initiative implements these
activities according to its specific mandate.
BACKGROUND INFORMATION
The World Bank
Making Motherhood Safe
Ten years after the launch of the Safe Motherhood Initiative, more than 1,500
women die every day in the developing world from preventable pregnancy-related
complications. Nearly 20,000 pregnancies a day result in stillbirths or infant deaths
within the first week of life. The death of a woman of reproductive age translates into
substantial economic and social hardship for her family and community. By ensuring
that women receive sufficient maternal care, and by providing women with effective
family planning services, many of these deaths can be avoided.
A SOCIAL AND ECONOMIC CHALLENGE
Although women's health is vital to sustainable development, it receives little
attention in the developing world. Maternal mortality rates, for example, show the widest
disparity between industrial and developing countries of any human development
indicator. Calculations by the World Bank show that improving health care for women
aged 15-44 offers the biggest return on health care spending for any demographic group
of adults (men or women). Furthermore, instead of crippling their nations' economies
healthy women become productive members of their societies and so do their healthy
children. Studies have shown that women are responsible for:
Providing 70 to 80 percent of the health care in developing countries;
Heading at least 20 percent of all households in Africa and Latin America;
Growing 80 percent of the food consumed domestically in parts of Africa and at least
50 percent of export crops; and
Earning 40 to 60 percent of household income, if home production is valued.
As the World Bank recognizes women's role in eradicating poverty and enabling
development, the Bank supports member governments, along with other assistance
agencies and non-governmental organizations to develop programs and implement
policies that will make pregnancy and birth as safe as possible for women and children.
The World Bank now has over 100 projects with women's health components in over
seventy countries. Lending has averaged US$490 million over the last three years for
reproductive health (family planning, maternal health and STDs/AIDS control) compared
to US$170 million in 1990.
WORKING TOGETHER
Safe motherhood is a community responsibility. It can only happen if
governments, international development organizations, community-based grass-roots
groups, businesses, and private citizens work together. In an effort to reduce the high toll
of maternal morbidity and mortality, the World Health Organization, United Nations
Children's Fund, United Nations Fund for Population Activities, the World Bank, IPPF,
and the Population Council formed the Inter-Agency Group for Safe Motherhood in 1987
and launched the Safe Motherhood Initiative. The initiative was launched in response to
the lack of cohesion and information available and the inevitably faltering political and
donor commitment to safe motherhood interventions. The goal of the program is to
reduce maternal mortality and disability by sharing existing information and establish a
consensus on the most effective interventions, revitalize the existing commitments, and to
raise awareness among new audiences, specifically businesses and social leaders, about
the importance of safe motherhood practices.
SAFE MOTHERHOOD IN ACTION
In India, the government's Child Survival and
Safe Motherhood Initiative, was launched in
Reproductive and Child Health: India
1992 with the assistance of the World Bank
In this unprecedented World Bank-supported
and UNICEF. The project has contributed to
project the government is working hand in
a 20 percent increase in the number of
hand with the community it is trying to help.
children fully immunized and a steadily rising
Consultation with the private sector and the
proportion of pregnant women who receive
community groups enables the creation of
pre-natal care and deliver their children in
reforms that most directly address the
hospitals.
problems of the rural poor. As a result of
these consultations, reform targets are
focused on providing accessible quality
In the fifth of a series of population projects
health and information services to the rural
in India, the World Bank has supported the
poor, in addition to providing contraception
government's goal of improving the
information.
availability and quality of family planning
and maternal and child health services for poor urban families through the "Fifth
Population Project." This project reduced sickness and death for about 2.5 million
poor women and children by increasing the availability, quality, and use of temporary
birth control methods; by promoting birth spacing; and by supporting child health
services.
The Bangladesh Population and Health Project, financed by a consortium of donors,
supports Safe Motherhood by strengthening family planning and other health
services, including comprehensive maternal and neonatal care, training of birth
attendants, and upgrading health facilities.
In Indonesia the approach to Safe Motherhood is through partnership. By involving
public and private sector agencies and NGOs involved in maternal health, this project
seeks to improve the supply and demand for maternal health services, and to
strengthen the sustainability of these services at the village level.
Safe Motherhood goals are being obtained in Morocco by increasing availability to
contraceptives, reorganizing prenatal service delivery at the provider and facility
level, and by training traditional birth attendants.
Investing in women's health enables women to participate more fully in the
process and benefits of development, and is an integral part of the Bank's poverty
reducing strategy. By addressing the key problems affecting women throughout their life
cycle, governments can improve human welfare and national economic efficiency. The
international disposition to work towards better women's health is unprecedented. In
partnership, governments, other international assistance agencies, and local communities
have the power to build on this positive global outlook and on the models and strategies
that have been developed locally to improve the health and nutrition of women. Both as a
catalyst for, and a partner in development, the World Bank acknowledges that
governments and people must make their own decisions about their future and the Bank
stands ready to assist them.
RECENT WORLD BANK PUBLICATIONS ON SAFE MOTHERHOOD
1997. Investing in Young Lives: The Role of Reproductive Health
1997. Health, Nutrition, & Population Sector Strategy Paper
1996. Improving Women's Health in India
1996. India's Family Welfare Program
1995. Safe Motherhood Initiative Pamphlet
1994. A New Agenda: For Women's Health and Nutrition
1994. Population and Development
1994. Women's Health and Nutrition: A World Bank Discussion Paper No. 256
Prepared by External Affairs, February 1998
FOR MORE INFORMATION
CONTACT: Benna Holden
(202) 973-0369
"Year of Safe Motherhood"
FACTS AT A GLANCE
Every minute of every day. somewhere in the world, a woman dies from complications related to pregnancy or
childbirth (defined as a maternal death).
Approximately 50 million women a year (equivalent to the total population of the countries of Spain and
Portugal) suffer maternal health complications.
In developing countries, pregnancy and childbirth are the leading causes of death, disease and disability among
women of reproductive age:
Leading Causes of the Burden of Disease in Women Aged 15-44 in the
Developing World, 1990
Respiratory infection
which
25%
Anema
-
25%
Self inflicted injures
3.2%
Depressive disorders
5.8%
HIV
6.6%
Tubercurosis
7.0%
STD
8.9%
Maternal causes
18.0%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Source: World Development Report 1993: Investing in Health. World Bank. Washington. DC. 1993
Worldwide. there are 430 maternal deaths for every 100,000 live births. In developing countries, the figure is
480 maternal deaths for every 100.000 live births; in developed countries there are 27 maternal deaths for
every 100.000 live births.
A woman's risk of dying from pregnancy and childbirth varies widely by region:
Region
Risk of Dying
Africa
1 in 16
Asia
I in 65
Latin American & Caribbean
I in 130
Northern Europe
I in 4,000
North America
I in 3,700
All developing countries
1 in 48
All developed countries
1 in 1,300
Country-level differences are even more dramatic: for example, in Ethiopia, 1 out of every 9 women die from
pregnancy-related complications. as compared to 1 in 8,700 in Switzerland.
There are five main causes of maternal death worldwide:
Causes of Maternal Death
severe bleeding
25%
infection 15%
indirect causes
20%
other
eclampsia 12%
direct causes 8%
obstructed labour
unsafe abortion
8%
13%
Source: Maternal Health Around the World. WHO. 1997
Deliveries by Relatives or Alone, Selected Countries
Each year, 60 million deliveries take place in
which the woman is cared for only by a family
Delivery by
Delivery alone
member. an untrained traditional birth
relative/other (%)
(%)
attendant -- or no one at all.
Malawi
41
7
Uganda
35
12
Niger
24
17
Nepal
56
11
Pakistan
52
2
Source: Demographic and Health Surveys. selected countries. various years.
Skilled Attendance at Delivery and Maternal
Mortality Ratios, selected countries
98%
100%
94%
1000
1000
Countries where skilled attendance at delivery
77%
850
800
75%
is low tend to have higher rates of maternal
Skilled Attendance at
650
250
Maternal Mortality Ratio
death and disability. In 1996, skilled birth
600
Delivery
46%
attendants were present at only 53% of births
50%
in the developing world. In developed
31%
400
countries. skilled attendance is nearly
25%
universal.
200
140
5%
20
0%
0
Trinidad
&
SriLanka
Botswana
Bolivia
Nigeria Bangladesh
Tobago
Skilled Attendance at Delivery
Maternal Mortality Ratio
Source: "Revised 1990 Estimates of Maternal Mortality". WHO. 1996 and "Coverage of Maternal Care". WHO. 1997
Child Deaths When a Parent Dies, per 1,000
200
Motherless children are likely to get
150
less health care and education as they
grow up. A study in Bangladesh
100
found that when a mother dies, her
50
children - especially daughters - are
0
much more likely to die than children
:
no parent dies
father dies
mother dies
whose parents are both alive.
:
sons
daughters
Source: Mother Buby Package Implementing Sufe Motherhood in countries. WHO, 1994
Most maternal deaths, millions of cases of disease and disability. and the deaths of at least 1.5 million infants
each year could be prevented through:
=
basic maternal care for all pregnancies, including a skilled attendant (doctor or midwife) at birth:
=
prevention and treatment of complications during pregnancy, delivery and after birth; and
11
postpartum family planning and basic neonatal care.
These health care services would cost approximately $3 per person per year in most developing countries.
###
MEDICUS GROUP
Safe Motherhood Initiative
"To be a Mother"
TV :60
3/11/98
ANNCR VO:
How to hold your baby.
how to be there for your baby. If you die
And if you die, chances are your baby will
To be a mother, you must know these
Feed and care for your baby.
while giving birth, you can't be there.
too.
things.
But most important,
So if you or someone you love is pregnant,
to take action if you see any of these signs
If your waters break, even a little.
Because before you can hold and comfort
see a healthcare worker. And be prepared
Bleeding, severe headache, or fever.
If your birth pains last more than a day,
and love,
get to a healthcare worker immediately.
O
Safe
Motherhood
S
UNFPA
UNICEF
WHO
THE WORLD BANK
PPF
Creative: Lisa Reswick, Paula Raymond,
POPULATION COUNCIL
Penny Hawkey - Medicus Group
Producer: Maxine Danowitz
before you can care for your baby, you
The Safe Motherhood Initiative.
Because our mothers are our future.
Editor: Alan Eisenberg - Horn/Eisenberg
must first care for yourself.
Sound: Leonard Hospidor - Russo/Grantham -
Back Pocket Studios
MEDICUS GROUP
Safe Motherhood Initiative "I thought my baby
"
TV :60
3/11/98
OVERLAPPING MOTHERS' VO:
I knew she'd have lots of curly
I thought he'd be strong
Her father's smile
I thought I'd be there to see it
I thought my baby would look
hair,
The biggest eyes
(Mothers fade away)
just like me
ANNCR VO: Every minute of
Almost 600,000 women each
sisters, workers, wives.
And when they die or become ill,
Yet, more than 90% of these
every day, a woman dies during
year - a tragic loss of our
their babies often do too.
women could be saved
pregnancy or childbirth.
nation's daughters,
O
Safe
Safe
Motherhood
UNFPA
S
is
Motherhood
UNICEF
FCI
WHO
P.O. Box 902
THE WORLD BANK
NY, NY 10274 USA
IPPF
POPULATION COUNCIL
www.safemotherhood.org
for as little as $2 per person per
simple, affordable health and
To find out how your government
The Safe Motherhood Initiative.
Because our mothers are our
year. The Safe Motherhood
education programs save lives.
and community can help, visit our
future.
Initiative has developed
website or write us today.
Creative: Lisa Reswick, Paula Raymond, Penny Hawkey - Medicus Group
Producer: Maxine Danowitz
Editor: Alan Eisenberg - Horn/Eisenberg
Sound: Leonard Hospidor - Russo/Grantham - Back Pocket Studios
is
Adolescent Sexuality and Childbearing
Adolescent pregnancy is alarmingly common in many countries. Every year, adolescents* give birth to 15 million
infants.¹ These young girls face considerable health risks during pregnancy and childbirth. Girls aged 15-19 are
twice as likely to die from childbirth as women in their twenties; those under age 15 are five times as likely to
die.² Because early childbearing is SO frequent, and carries SO many health risks, pregnancy-related complica-
tions are the main cause of death for 15-19 year old girls worldwide.³
Sexual Behaviour and Childbearing
Globally, most people become sexually active during ado-
Sexual Activity Among Women Age 15-19⁴
lescence. Rates are highest in sub-Saharan Africa, where
Married
60%
more than half of girls aged 15-19 in seven countries are
60
Single, sexually active
52%
sexually experienced.
50
48%
Millions of adolescents are bearing children. In sub-
40
Sexual Activity %
35%
Saharan Africa, more than half of women give birth before
30
26%
age 20. In Latin America and the Caribbean, this figure
20%
20%
20
18%
18%
drops to one third.⁵
11%
10
6%
5%
n/a
n/a
0
Botswana
United
Jamaica
Kenya
Custa Rica Bangladesh Indonesia
States
Why Is Adolescent Pregnancy so Common?
A lack of information and services: Adolescents often have
Cultural values: In many developing countries, female sta-
poor information about reproduction and sexuality, and
tus is equated with marriage and motherhood. Adolescents
little access to family planning and reproductive health
often marry early; more than 50 countries allow marriage
services.
at age 16 or below, and seven allow marriage as early as
age 12." Even the youngest brides face immediate pressure
In Sri Lanka, one-third of young adults age 16-24 did not
to prove that they are fertile.⁷
know the duration of a normal pregnancy. Fewer than 5%
had discussed reproductive health with their parents.
Health Risks
Reproductive health problems and deaths are more com-
Maternal Mortality* by Age⁸
mon among sexually active adolescents than among
1400
20-34 years
women in their 20's and early 30's." Physiologically and
1270
15-19 years
1200
1100
socially, adolescents are more vulnerable to:
1000
860
- Maternal death: Girls age 15-19 are up to twice as likely
800
to die during pregnancy or delivery as women age 20-34.
600
575
479
526
436
400
- Infant and child mortality: Children born to adolescents
223
200
are more likely to die during their first five years of life
80
108
0
than those born to women age 20-29."
Ethiopia
Indonesia
Bangladesh
Nigeria
Brazil
- Sexually transmitted diseases (STDs): Each year, I in 20
Maternal deaths per 100,000 live births
adolescents worldwide contracts an STD (including
HIV/AIDS).¹
At Kenyatta Hospital in Nairobi, one-quarter of girls age
15-19 seeking antenatal care had an STD (gonorrboca,
chlamydia or herpes)."
*The World Health Organization defines adolescence as the period of life between ages 10 and 19.
SAFE MOTHERHOOD FACT SHEET
- Violence/sexual abuse: Adolescent girls may lack the confi-
- Unsafe abortion: Each year, girls age 15-19 undergo at
dence and decision-making skills to refuse unwanted sex.
least five million induced abortions.¹ Because abortion is
Girls who are subject to sexual abuse and rape can suffer
legally restricted in many countries, adolescents often resort
serious, life-long physical and emotional consequences.
to unsafe procedures by unskilled providers. Adolescent
girls therefore suffer a significant - and dispro-
In interviews with adolescents in Peru and Colombia,
portionate - share of death and disability from unsafe
60% said they had been sexually abused within the previous
abortion. 130
year.¹¹
Social and Economic Problems
A young mother's ability to meet her own needs and those of
In Kenya, 10,000 girls leave school each year due
her children can be jeopardised by:
to pregnancy."
A lack of education. Young women are often expelled
A lack of income. It can be difficult for young mothers,
from school if they become pregnant, and few ever return.
especially those without education or marketable skills, to
support themselves and their families financially.
Giving Girls Other Opportunities
Age at marriage: Delaying marriage often delays first birth,
Education: Women who have some secondary schooling
and can also reduce the total number of children a woman
are less likely to give birth during adolescence." On aver-
has, since she will spend fewer years in childbearing."
age, women with seven or more years of education marry
four years later and have 2.2 fewer children than those
with no education.14
What Can Be Done
Long-term policies and programmes must address the
- Removing legal, regulatory and cultural barriers to sexu-
underlying social, cultural and economic factors that con-
al and reproductive health information and services for
tribute to adolescent sexual activity and childbearing.
adolescents.
They must improve the status of women and girls and
expand their opportunities by:
- Providing appropriate, accurate sexual and reproductive
health education for young people, both in- and out-
- Encouraging family and community support for delayed
of-school.
marriage and childbearing.
- Designing and providing sensitive and confidential
- Expanding girls' access to higher quality education and
reproductive health services that respond to young peo-
training, and helping them build marketable skills.
ples' particular needs; help them make informed decisions
- Increasing income-earning abilities, opportunities to
about sexuality and negotiate safer sex; and emphasise
earn income and access to other resources for adolescent
the prevention of unwanted pregnancy, unsafe abortion
girls and women.
and STDs.
More immediately, programmes must make it possible for
*Each of the co-sponsors of the Safe Motherhood Initiative (see below)
all adolescents to take responsibility for, and protect, their
implements these activities according to HS specific mandate.
sexual and reproductive health by*:
Sources:
11: "Adolescent Reproductive Health". Network, 17(3). Spring, 1997.
I: "Issues in Brief: Risks and Realities of Early Childbearing Worldwide". Alan Guttmacher
12: S. Koontz and S.R. Conly, Youth at Risk: Meeting the Sexual Needs of Adolescents.
Institute, New York, 1997.
Population Action International, Washington, DC, 1994.
2: United Nations Dept. of International Economic and Social Affairs, The World's Women:
13: S. Singh, "Adolescent Childbearing and Pregnancy in Developing Countries: A Global
Trends and Statistics 1970-90. United Nations, New York, 1991.
Review". Workshop organized by Alan Guttmacher Institute. New York. 1997.
3: "Too Old for Toys, Too Young for Motherhook UNICEE New York. 1994.
14: N. Sadik, State of the World Population 1990. New York. UNFPA. 1990.
4: Senderowitz, "Adolescent Health: Reassessing the Passage to Adulthood". World Bank
Prepared by Family Care International (FCI) and the Safe Motherbood Inter-Agency Group
Discussion Papers #272, Washington, DC. 1995.
(IAG). The IAG includes the United Nations Children's Froud (UNICEF). United Nations
5:J. Hoberaft, notes prepared for the Safe Motherhood Technical Consultation in Sri Lanka, 18.
Population Fund (UNFPA). World Bank, World Health Organization (WHO), International
23 October 1997.
Planned Parentbood Federation (IPPF). and the Population Council: FCI serves as the secretariat.
(v: "Adolescent Health and Development: The Key to the Future". World Health Organization,
These fact sheets have also been prepared in more detailed versions for technical audiences. For
Geneva, 1995.
more information or copies of available materials. contact any IAG member, or the secretarial at:
7: N. Sadik, The State of World Population 1997. UNFPA. New York. 1997.
Family Care International
588 Broadway, Suite 503
S: "The Health of Youth. Facts for Action: Youth and Reproductive Health". World Health
New York. NY. 10012. USA
Organization, Geneva, 1989.
Tel: (212) 941-5300
9: G. Bicego et al., "Infant and Child Mortality", DHS Comparative Studies, No. 20. Macro
Fax: (212) 941-5563
International, Calverton, MD, 1996.
Email: [email protected]
Web site address: wwwe.safemotherbood.org
10: "Adolescent Reproductive Health in Developing Countries". CommonHealth: The Bulletin
of the Commonwealth Medical Association, #2. 1995.
1998
is
Every Pregnancy Faces Risks
Every time a woman is pregnant - which happens an estimated 200 million times every year around the world -
she risks a sudden and unpredictable complication that could result in her death or injury, and the death or injury
of her infant. At least 40% of all pregnant women will experience some type of complication during their preg-
nancies. For about 15%, this complication will be potentially life-threatening, and will require immediate
obstetric care.'
Which Women Are at Risk?
"Maternal risk" is defined as the probability of dying or
Some groups of women are more likely to develop preg-
experiencing a serious complication as the result of preg-
nancy complications than others (for example, if they had
nancy or childbirth.
a complication during a previous pregnancy). However,
it is almost impossible to predict which individual woman
will develop a life-threatening complication.3
What Is "Risk Assessment"?
Risk assessment is a tool used by health systems that aims
Risk assessment was developed to help health providers
to separate women into categories - typically "high risk"
allocate their time and resources to the women who need
and "low risk" - according to certain social, demographic
them most, especially in communities with limited
or physical characteristics such as educational status, age,
resources. However, a review conducted for the World
height, and number of pregnancies.³ Ideally, women who
Health Organization found that risk assessment has not
are defined as "high risk" are then given special care to
been an effective strategy for preventing maternal death.4
prevent or manage any health problems they may develop.
Risk assessment is usually conducted as part of antenatal
care during pregnancy.
Why Doesn't Risk Assessment Work?
The broad characteristics used by most risk assessment sys-
The same study in Zaire found that 71% of the women
tems are not precise enough to predict an individual
who did develop obstructed labour did not have any
woman's risk.256 As a result, a large number of women are
bistory of problems.
identified as "high risk", even though they never develop
Even if a woman is correctly identified as being at risk of
any complications.
complications, there is no guarantee that she will get
A study in Zaire found that 90% of women who were
appropriate care. Many health systems cannot provide ade-
identified as "at risk" for obstructed labour ended up not
quate services. Also, women themselves may be unable or
having any problem during delivery.⁷
unwilling to seek medical care when they are told they
- Most of the women who develop complications do not
are "high risk". They may lack financial resources to pay
have any risk factors, and are therefore classified as
fees, be too busy, face opposition from family members
"low risk".
or simply not want to go.
When Risk Assessment Fails
Women may not receive life-saving care. Women who are
Health systems are overburdened: Misdiagnosing women
identified as "low risk" can be fulled into a false sense of
can create a serious problem for health systems. They may
security. If this happens, they may fail to recognise the signs
find themselves overloaded and have to spend scarce time
of complications, and fail to seek appropriate services.⁵
and resources on unnecessary treatment for "high risk"
Personal cost and inconvenience is high. Women who
women who in fact never develop any complications.
are identified as "high risk" may waste valuable time and
Since risk assessment cannot predict which women will
spend scarce funds seeking unnecessary treatment.
experience pregnancy complications, it is critical that all
SAFE MOTHERHOOD FACT SHEET
women who are pregnant, in labour or recently had a baby
have access to high quality maternal health care. This
care must include services to manage serious pregnancy
complications if and when the need arises.
What Can Be Done
Governments and health providers need to recognise that
referrals; and treatment of a woman who is experiencing
every pregnancy is special, and should ensure that all
complications until she can be transferred safely to a
pregnant women have access to high-quality maternal
higher level of care.
health services by:
- Ensuring that a functioning system of communication
- Educating women and their families about the risk of
and transportation links health workers who are working
complications faced by all women, and about actions
in communities, health centres and hospitals SO that
they should take if and when a problem arises.
women with pregnancy complications can receive prompt
and appropriate medical care.
- Providing adequate care as close as possible to where
women live. Services should include clean deliveries by
- Improving women's overall well-being and reproductive
health workers who have been trained in midwifery;
health through prevention and through screening and
prompt recognition of complications and appropriate
treatment for existing problems that contribute to poor
reproductive health.
Sources:
1: M. Koblinsky, et al., "Mother and More: A Broader Perspective on Women's Health", III M.
Prepared by Family Care International (FCI) and the Safe Motherbood Inter-Agency Group
Koblinsky, et al., eds., The Health of Women: A Global Perspective. Westview Press. Oxford,
(IAG). The IAG includes: the United Nations Children's Fund (UNICEF). United Nations
1993.
Population Froud (UNFPA). World Bank. World Health Organization (WHO). International
2: Winikoff, "Maternal Risk". Paper presented at Berzelius Symposum, Stockholm, Sweden,
Planned Parentho of Federation (IPPF). and the Population Council: FCI serves as the secretariat.
1991.
These fact sheets have also been prepared IN more detailed versions for technical audiences. For
3: W. Graham, "Every Pregnancy Faces Risk". Presentation at Safe Motherhood Technical
more information OF copies of available materials. contact any IAG member, or the secretariat at:
Consultation in Sn Lanka, 18-23 October 1997.
Family Care International
4:C. Rooney, Antenatal Care and Maternal Health: How Effective Is IR? A Review of the
588 Broadway, State 503
New York, NY. 10012 USA
Evidence" (WHO/MSM/92.4). World Health Organization, Geneva, 1992.
Tel: (212) 941-5300
5: E.A. Yuster, "Rethinking the Role of the Risk Approach and Antenatal Care in Maternal
Fax: (212) 941-5563
Mortality Reduction". International Journal of Gynecology and Obstetrics 50(2). 1995
Email: [email protected]
6: JE. Rhodes, "Removing Risk from Safe Motherhood". International Journal of Gynecology
Web site address: www.safemotherbood.org
and Obstetrics 50(2). 1995.
1998
7: Maine, Safe Motherbood Programs: Options and Issues. Center for Population and Family
Health, Columbia University, New York. undated.
is
Skilled Care During Childbirth
The single most important way to reduce maternal deaths is to ensure that a skilled health professional is pre-
sent at every birth. However, there is a serious shortage of these professionals in developing countries. Whether
by choice or out of necessity, 60 million women in the developing world give birth each year without skilled
help - cared for only by a traditional birth attendant, a family member, or no one at all.¹
Skilled care during childbirth is important because millions of women and newborns develop serious and hard-
to-predict complications during or immediately after delivery. Skilled attendants - health professionals such as
doctors or midwives who have midwifery skills - can recognise these complications, and either treat them or
refer women to health centres or hospitals immediately if more advanced care is needed.
Unassisted Births Are Common and Can Be Fatal
More than three-quarters of all maternal deaths in develop-
Skilled Attendance at Delivery and Maternal
ing countries take place during or soon after childbirth.
Mortality Ratios, selected countries¹, 3
100
98%
94%
1000
1000
In 1996, skilled birth attendants were present at only 53%
80
77%
850
of births in the developing world.¹ In developed countries,
800
skilled attendance is nearly universal.
Skilled Attendance at Delivery %
650
60
600
46%
Countries where skilled attendance at delivery is low tend
40
31%
400
to have higher rates of maternal death and disability.
Maternal Mortality Ratio
250
20
200
140
5%
90
0
0
Trinidad &
Sri
Lanka
Botswana
Bolivia
Nigeria Bangladesh
Tobago
Skilled Attendance at Delivery
Maternal Mortality Ratio
Maternal Deaths per 100,000 Live Births
Who Should Provide Care During Childbirth?
The best person to provide assistance during childbirth is a
Skilled attendants include doctors, nurses, midwives and
health professional with midwifery skills who lives in or
other health workers with midwifery skills who can diag-
near to the community he or she serves.
nose and manage complications during childbirth, as well
as assist normal deliveries."
Most midwives work in hospitals and urban areas. They
are scarce in rural areas - where 80% of developing coun-
Adequate equipment, drugs and supplies are essential to
try populations live.
enable skilled attendants to provide good quality care. In
addition, skilled attendants need to be supported by appro-
In parts of Asia and Africa, there is only one midwife for
priate supervision. When delivery is taking place in the
every 15,000 births.⁵
village (at home or in a local health facility), an emergency
transport system must be available to take women to facili-
Number of Midwives per 100,000 Births, Selected Countries⁴
ties that can provide more advanced care.
120
102
100
80
60
40
40
20
16
14
5
0
Dom. Rep
India
Haiti
Ghana
Kenya
SAFE MOTHERHOOD FACT SHEET
Care in the Community
In developing countries, women commonly seek the help of
In many places, especially in Asia and Africa, women give
traditional birth attendants: community members who
birth with the help of a relative, or alone.
deliver infants according to local customs and beliefs. In
some - but not all - communities, these attendants may
Deliveries by Relatives or Alone, Selected Countries'
have some training to help them avoid harmful practices,
Delivery by
Delivery alone (%)
relative/other (%)
conduct clean deliveries, recognise danger signs and refer
women to health facilities if they have any complications.
Malawi
41
7
However, without emergency back-up support (including
Uganda
35
12
Niger
24
17
referral to a district hospital), training traditional birth
Nepal
56
11
attendants does not decrease a woman's risk of dying in
Pakistan
52
2
childbirth.7
Training Needs
As countries try to ensure that a qualified health profes-
- Supervision and refresber training in family planning and
sional is present at the birth of every child, they face a
maternal health are often inadequate.* In Uganda, for
number of significant problems:
example, a study found that only 28% of midwives had
ever taken a refresher course."
- Existing health workers often lack the skills they need to
save the lives of women who suffer emergency complica-
- Many midwives and physicians have no training in tra-
tions. These skills include the ability to prevent, identify
ditional belief systems, communication and community
and treat problems such as shock, haemorrhage, infection
organising.* These topics are needed to ensure that a
(sepsis), and eclampsia (convulsions from high-blood pres-
health worker is an accepted part of the community she
sure), and to manage abortion complications.
or he serves.
- Curricula used to teach midwifery skills are often out of
date and do not reflect new techniques and research.
Many of these curricula are adapted from developed coun-
try models and do not reflect the limited resources and
poor working conditions in developing countries.
What Can Be Done
Increase the number of health professionals with mid-
Upgrade, establish and expand comprehensive midwifery
wifery skills in under-served regions, particularly poor
training programmes that include life-saving skills for
and rural areas.
dealing with obstetric emergencies.
Train, authorise and equip midwives, nurses and commu-
Create clearly-defined protocols for routine care and the
nity physicians to provide all feasible obstetric services
management of complications.
needed within communities, especially emergency interventions, and
Establish systems for supervising and supporting skilled
to prescribe medication. Establish systems for training, supervising
birth attendants, and for emergency referral and treatment.
and supporting these providers, and for linking them to higher-level
health facilities for back-up.
Sources:
1: "Coverage of Maternity Care: A Listing of Available Information, Fourth Edition". World
9: "Strengthening Midwitery Within Safe Motherhood: Report of a Collaborative
Health Organization, Geneva, 1997.
ICM/WHIO/UNICEF Pre-Congress Workshop". World Health Organization, Geneva, May 1996.
2: AbouZahr, "Improve Access to Quality Maternal Health Services". Presentation at Safe
Motherhood Technical Consultation in Sri Lanka, 18-23 October 1997.
Prepared by Family Care International (FCI) and the Safe Motherbood Inter-Agency Group
3: "Revised 1990 Estimates of Maternal Mortality: A New Approach by WHO and UNICEF".
(IAG). The IAG includes: the United Nations Children's Froud (UNICEF). United Nations
World Health Organization, Geneva, 1996.
Population Fund (UNFPA). World Bank. World Health Organization (WHO). International
4: "Midwitery Education: Action for Safe Motherhood, Report of a Collaborative Pre-Congress
Planned Parentbood Federation (IPPF). and the Population Comeil: FCI serves as the secretariat.
Workshop". World Health Organization, Geneva, October 1990.
These fact sheets have also been prepared in more detailed versions for technical audiences. For
5:J. Fortney, "Ensuring Skilled Attendance at Delivery: The Role of TBAs". Family Health
more information or copies of available materials, contact any IAG member, or the secretariat at:
International, Research Triangle Park, NC. 1997.
Family Care International
6: WHO/FIGO/International Confederation of Midwives, "Definition of the Midwife". 1992.
588 Broadway. Suite 503
New York. NY, 10012, USA
7: A. Tinker and M. Koblinsky, Making Motherboo of Safe. World Bank, Washington, DC, 1993.
Tel: (212) 941-5300
8: Demographic and Health Surveys, selected countries, various years. Macro International,
Fax: (212) 941-5563
Calverton, MD.
Email: [email protected]
Web site address: www.safemotherbood.org
1998
Good Quality Maternal Health Services
Millions of women do not have access to good quality health services during pregnancy and childbirth - especially
women who are poor, uneducated or who live in rural areas.' Less than half of women in developing countries get ade-
quate health care during and soon after childbirth, despite the fact that most maternal deaths take place during these
periods.¹ In contrast, use of maternal health services is nearly universal in developed countries.
Access means that services are available and within reach of women who need them. Good quality services require
that health care providers have adequate clinical skills and are sensitive to women's needs; that facilities have nec-
essary equipment and supplies; and that referral systems function well enough to ensure that women with
complications get essential treatment.
Many Women Lack Maternal Health Care
At least 35% of women in developing countries receive no
Maternity Care: The Percentage of Women Who²:
Make at Least 1 Antenatal Visit
antenatal care during pregnancy, almost 50% give birth
100
97%
98%
99%
95%
Deliver with Skilled Attendance
without a skilled attendant and 70% receive no postpar-
80
73%
75%
tum care in the six weeks following delivery. This lack of
63%
65%
60
care is most life-threatening during labour, childbirth and
53%
42%
the days immediately after delivery, since these are the
40
times when sudden, life-threatening complications are most
20
likely to arise.
0
Africa
Asia
Latin America &
Europe
North America
the Caribbean
Why Women Do Not Use Available Services
No physical access: Most rural women (80%) live more
Poor information: Women and community members often
than five kilometres from the nearest hospital. Vehicle
do not know how to recognise, prevent or treat pregnancy
shortages and poor road conditions mean that walking is
complications, or when and where to seek medical help.
often the main mode of transportation, even for women
In Ghana, 64% of women who died of pregnancy compli-
in labour.¹
cations sought help from a traditional healer before going
In rural Tanzania. 84% of women who gave birth at home
to a health facility. Families cited cost and their belief that
intended to deliver at a health facility, but could not
the woman was not ill enough as the main reasons for not
because of distance and the lack of transport.3
seeking hospital care.'
High costs: Millions of women cannot afford to use mater-
Cultural preferences: Formal health services can conflict
nal health services. Even when formal fees are low or
with ideas about what is normal and acceptable, including
non-existent, women often face hidden fees and expenses
preferences for privacy, modesty and female attendants.
for transport, drugs, and food or lodging for the woman or
The Saraguro Indians in Ecuador shun affordable, accessi-
her family members.
ble maternity care because they feel that hospitals violate
women's privacy during childbirth and because many
Impact of User Fees on Obstetric Admissions, Zaria, Nigeria
health providers are men.'
Obstetric
Fees for some
Increases
services
services
in fees (1988)
Lack of decision-making power: In many parts of the
free (1983)
introduced (1985)
Obstetric
world, women's power to make decisions is limited, even
admissions
7,450
5,437
3,376
over matters directly related to their own health.
Deliveries
6,535
4,377
2,991
In Bangladesh, it is usually the mother-m-law and husband
Maternal deaths
2
1
62
who make the decision to seek (or not seek) care. Studies
have found that they are the least likely 10 know about
pregnancy-related complications and their possible fatal
consequences."
SAFE MOTHERHOOD FACT SHEET
Health Services Are Inadequate
Poor quality of care is one of the most common reasons
- Other factors include: a lack of privacy; run-down physi-
women give for choosing not to use available maternal
cal facilities; inconvenient operating hours; and restrictions
health services. Problems include:
on who can stay with a woman at the health facility.*
- Health facilities in developing countries face chronic
Delays in referring women from community health facilities
shortages of equipment, drugs and basic supplies, includ-
to hospitals are one of the most important barriers to life-
ing blood for transfusion. Families of women in labour
saving maternal care.
may be forced to purchase drugs and supplies to bring to
In Masavingo, Zimbabwe, a significant proportion of
the hospital,⁷ which can cause fatal delays.
maternal deaths were caused by "avoidable factors".
- Health facility staff are often poorly trained. They may
including failure by health workers to identify women suf-
lack both life-saving and basic clinical skills, and may not
fering from serious pregnancy-related complications and to
observe hygienic practices.
refer them to a higher level of the health care system."
- Health workers may be rude, unsympathetic and uncar-
A study of 718 maternal deaths in Egypt found that 92%
ing, so women prefer to use the services of traditional birth
of them could have been avoided if good quality care had
attendants and healers.
been provided.¹
Improving the quality of existing maternal health services is the quickest,
Provide technical competence:
most cost-effective way to save women's lives:
Staff members should be trained in technical, clinical, management, and
Good quality care aims to:"
interpersonal skills;
Meet women's needs:
Standards of care and written protocols should be available;
Services should be provided In health facilities that are as close as possi-
ble to where women live and that can provide the services safely and
Physical facilities should be adequate, clean and convenient;
effectively;
Necessary drugs, equipment and supplies should be available,
Services should be sensitive to cultural and social norms, such as prefer-
Comprehensive reproductive health services (including follow up care)
ences for privacy, confidentiality and care by female health workers;
should be available on-site or through established linkages to other
health facilities;
Staff should be respectful, non-judgmental and responsive to clients;
Women should be treated as active participants in their own health, and
A fully functional referral and transport system should exist between all
offered information and counselling SO they can make informed decisions
levels of care (home/community, health centres, and district/regional
about their health and treatment.
hospitals).
What Can Be Done
Governments and non-governmental agencies must
- Enforcing standards and protocols for service delivery,
expand services, improve their quality, and tailor them to
management and supervision, and using them to monitor
meet the needs of women and communities by:
and evaluate the quality of services, along with feedback
- Ensuring that health facilities are located close to where
from clients and health providers.
women live, have an adequate number of trained staff, a
- Providing free or affordable maternal and infant health
continuous supply of drugs and equipment, and are
services that manage any complications as well as offer
linked to hospitals by an emergency transport and refer-
routine care.
ral system.
- Educating women and communities about the impor-
tance of maternal health and appropriate services.
Sources:
I:C. AbouZahr. "Improve Access to Quality Maternal Health Services". Presentation at Safe
9:5 Faweus et al., "A Commumity-based Investigation of Avoidable Factors for Maternal
Motherhood Consultation in Sri Lanka. 18-23 October 1997.
Mortality in Zimbabwe". Studies in Family Planning, Vol. 27. No. 6, November-December 1996.
2: "Coverage of Maternity Care: A Listing of Available Information, Fourth Edition". World
10: M. Kassas, et al., "The National Maternal Mortality Study of Egypt 1992-1993".
Health Organization, Geneva, 1997.
International fournal of Gynecology and Obstetrics, Vol. 50 (Supplement 2). October 1995.
3: G. Biego CI al., Survey on Adult and Childhood Mortality, Tanzania. Macro International,
11: Mother-Baby Package: Implementing Safe Motherhood III Countries. World Health
Calverton, MD. 1995.
Organization, Geneva, 1994.
4: H. Odoi-Agyarko, N. Dollimore, O. Owusu-Argyei, "Risk Factors in Maternal Mortality: A
Prepared by Family Care International (FCI) and the Safe Motherbood Inter-Agency Group
Community-Based Study in Kassena Nankani District". Paper presented at the National
(IAG). The IAG includes: the United Nations Children's Froud (UNICEF). United Nations
Consultative Meeting on Sate Motherhood, Accra. Ghana, January 1993.
Population Fund (UNFPA). World Bank. World Health Organization (WHO). International
5:1. Leshe and G.R. Gupta, "Unlization of Formal Services for Maternal Nutrition and Health
Planned Parentbood Federation (IPPF). and the Population Council: FCI serves as the secretariat.
Care". International Center for Research on Women, Washington, DC, February 1989.
These fact sheets have also been prepared in more detailed versions for technical audiences. For
6: "Safe Motherhood: A Woman's Right to Life, Information Kir". Ministry of Health and
more information or copies of available materials. contact any IAG member, or the secretariat at:
Family Welfare, Bangladesh, 1997.
Family Care International
7:S. Thaddeus and D. Maine, "Too Far to Walk: Maternal Mortality in Context." Social Science
588 Broadway, Suite 503
Medicine 38(8). 1994.
New York. NY, 10012. USA
Tel: (212) 941-5300
S: C. AbouZahr. C. Vlassoff and A. Kumar, "Quality Health for Women: A Global Challenge".
Fax: (212)941-5563
Health Care for Women International, Vol. 17. 1996.
Email: [email protected]
Web site address: www.safemotherbood.org
1998
is
Unwanted Pregnancy
There are an estimated 200 million pregnancies around the world each year. Approximately one-third of these, or
75 million, are unwanted.' These pregnancies contribute to maternal health problems in two ways: first, many
pregnancies are unwanted for reasons that can threaten the woman's health or well-being; she may have an
existing health problem, or lack the support and resources she needs to have a healthy pregnancy and raise a
healthy child. Second, where women do not have access to safe abortion services, many unwanted pregnancies
are terminated using unsafe procedures that can lead to the woman's death or disability.
Unwanted Pregnancy Can Be Deadly
Every year, approximately 50 million unwanted pregnan-
developing countries, causing the deaths of at least 200
cies are terminated. Some 20 million of these abortions
women each day.
are unsafe. About 95% of unsafe abortions take place in
Why Do Unwanted Pregnancies Occur?
Although unwanted pregnancy occurs for many reasons,
Unmet Need for Family Planning*.
the most common are non-use of contraception or contra-
40
Selected Countries
37%
35%
ceptive failure:
30
27%
26%
- Between 120 and 150 million married women want to
25%
stop having children or postpone their next pregnancy,
20
but are not using contraception. An additional 12 to 15
14%
million unmarried women also want to avoid pregnancy
10
but lack the means to do so.¹
0
- An estimated 8 to 30 million pregnancies each year result
Ghana
Bolivin
Tanzania
Philippines
Ecuador
Indonesia
.
from contraceptive failure - either because the method
Percentage of women who would like stop childbenring or space their next
birth but are not using contraception.
was used inconsistently or incorrectly, or because the
method failed.
Cultural Traditions Can Limit the Use of Contraception
In many countries women have little control over sexual
ceptives. Opposition from husbands is one of the most
relations and contraceptive use. Social expectations and
common reasons women give for not using contraception.
pressures define what is or is not acceptable for a woman
- Between 20% and 50% of women and girls report having
to do, and can make it difficult for a woman to protect
been subject to sexual coercion, abuse or rape.⁵ Such
herself from unwanted pregnancy:
women are at high risk for unwanted pregnancy and other
- Social taboos and unequal power relations between
sexual and reproductive health problems.
men and women often prevent women from using contra-
Contraceptives Are Still Out of Reach
Although nearly 60% of women and men around the
Prevalence of Modern Contraceptive Use'
world use modern contraceptive methods, 350 million cou-
80
ples do not have access to a full range of family planning
67%
60
methods, services and information.'
55%
49%
45%
Women do not always know where to get family planning
40
services. The proportion of married women age 15 to 49
who know where to obtain a modern contraceptive varies
20
15%
widely within regions: from 22% in Mali to 96% in
0
Zimbabwe; from 45% in Pakistan to 99% in Thailand;
N. America
Asia
Latin America
Europe
Africa
& Caribbean
SAFE MOTHERHOOD FACT SHEET
from 61% in Bolivia to 98% in Colombia and 99% in
EMERGENCY CONTRACEPTION
Trinidad and Tobago.¹
Emergency 10011 emplion quart that
can 1,11 used-affer unpostecte (11: noth is for the
Use of male contraceptives is low. In Brazil, condoms and
woman in di SDPT.) 'I pills '''' emar-
vasectomy account for less than 4% of total contraceptive
gency contral plls CP i! at sexual
use". Comparative figures in Iran are 6% for condoms and
ntersourse ECP. aug been -! method Emergency
contracention 11.1° 1111 nob relate 212 ented preq
1% for vasectomy.⁷
name, Never The
Inadequate Family Planning Programmes
Even where family planning services are available, they
- Promotion of methods that may be inappropriate for a
may not respond to people's needs and preferences. In
particular client.' This can happen because facilities have
many countries, shortcomings in the quality of family plan-
limited contraceptive supplies, or because service providers
ning programmes include:
do not spend enough time discussing clients' needs or
decide for their clients what methods they should use.
- A focus on quantitative goals (such as the percentage of
women using a contraceptive method) instead of helping
- Poor clinical skills and procedures, for example during
clients achieve their personal goals for the number and
pelvic exams, sterilisation and IUD insertions, which can
timing of their children."
cause the client unnecessary pain or infection."
- Poor information and counselling. Studies in sub-Saharan
- Weak or non-existent links to other reproductive health
Africa found only 25-54% of new contraceptive users were
services, including treatment of STDs, that are needed to
informed about side effects.¹
preserve a woman's health and future ferrility."
What Can Be Done
Governments and donors need to make programmatic
Policy-makers need to address regulatory, social, economic
changes to:
and cultural factors within communities and at the national
level to:
- Ensure that all individuals - including adolescents and
unmarried women - have access to good quality, confi-
- Ensure that women have control over their sexuality and
dential family planning services which: offer a full range
reproduction, rectify power imbalances between men and
of methods, including emergency contraception; are
women, and promote caring, responsible behaviour
responsive to the needs and lifestyles of their clients; and
among men in sexual relations, contraception, pregnancy
enable women and men to have the number of children
and childcare.
they want, while protecting themselves against sexual and
- Address sexual coercion and all forms of sexual violence
reproductive health problems.
against women.
- Ensure that all providers of care have the supplies, infor-
- Address the problem of unwanted pregnancy among
mation, and technical and communication skills necessary
young people, and modify attitudes that stigmatise
for offering high quality care.
pregnant girls.
- Offer reliable information and compassionate counselling
to all women with an unwanted pregnancy, including
information about when and where a pregnancy may be
"Each of the co-sponsors of the Safe Motherhood Initiative (see below)
legally terminated.*
implements these activities according to its specific mandate.
Sources:
S: PATH. "Emergency Contraceptive Pills: Safe and Effective But Not Widely Used". Outlook,
1: N. Sadik, The State of World Population 1997. UNFPA. New York, 1997.
14(2), September 1996.
2: Abortion: A Tabulation of Available Data on the Frequency and Mortality of Unsafe Abortion,
9: Reconsidering the Rationale. Scope and Quality of Family Planning Programs. The Population
3rd edition. World Health Organization, Geneva, 1997 (in press).
Conncil, New York, 1994.
3: Women's Lives and Experiences: A Decade of Research bundings from the Demographic and
Prepared by Family Care International (FCI) and the Safe Motherbood Inter-Agency Group
Health Surveys Program. Macro International, Calverton, MD. 1994.
(IAG). The IAG includes: the United Nations Children's Froud (UNICEF). United Nations
Population Froud (UNFPA). World Bank. World Health Organization (WHO). International
4: S.J. Segal and K.D. LaGuardia. "Termination of Pregnancy A Global View". Balliere's
Planned Parentbood Federation (IPTF). and the Population Council: FCI serves as the secretariat.
Clincal Obstetric and Gynaecology, Vol. 4, No. 2, 235-247, 1990.
These fact sheets have also been prepared in more detailed versions for technical audiences. For
5: Heise. K. Moore. N. Toubia, "Sexual Coercion and Reproductive Health: A Focus on
more information or copies of available materials, contact any IAG member. or the secretariat at:
Research". Population Council. New York. 1995.
Family Care International
6: Brazil: Programme Review and Strategy Development Report. UNFPA. New York, 1992.
588 Broadway, Suite 503
7: Islamic Republic of Iran: Programme Review and Strategy Development Report. UNFPA,
New York. NY. 10012. USA
New York, 1994.
Tel: (212) 941-5300
Fax: (212) 941-5563
Email: [email protected]
Web site address: www.safemotherbood.org
1998
is
Unsafe Abortion
Each year, approximately 20 million unsafe abortions are performed worldwide.* They result in nearly 80,000
maternal deaths and hundreds of thousands of disabilities.¹ In some countries, unsafe abortion is the most com-
mon cause of maternal death.¹ It is also one of the most easily preventable and treatable.
Deaths from Unsafe Abortion
Every day, 55,000 unsafe abortions take place - 95% of
Unsafe Abortion: Regional Estimates of Mortality and Risk of Death'
them in developing countries. They are responsible for one
Risk of dying after
% of maternal deaths
in eight maternal deaths. Globally, one unsafe abortion
unsafe abortion
due to unsafe abortion
Africa
1 in 150
13%
takes place for every seven births.¹
Asia"
I in 250
12%
Latin America
1 in 900
21%
Europe**
1 in 1900
17%
*Excludes Japan, Australia and New Zealand
Primarily Eastern Europe
Disabilities and Health Problems
Between 10% and 50% of all women who undergo unsafe
fewer social contacts and less financial means to obtain an
abortions need medical care for complications.¹
abortion safely.3 Young women are also more likely to
delay pregnancy termination until late in pregnancy when
- The most frequent complications are incomplete abortion,
the risk of complications is higher.
infection (sepsis), haemorrhage and injury to the internal
organs, such as puncturing or tearing of the uterus.¹
DANGEROUS METHODS AND PROCEDURES USED TO INDUCE
ABORTION INCLUDE:
- Long-term health problems include chronic pain, pelvic
Inserting objects (sticks, wires, knitting needles) into the uterus.
inflammatory disease and infertility.
Drinking poisonous or harmful substances (including herbs,
In many African countries, up to 70% of women treated
bleach and hair dye)
for abortion complications are younger than 20.²
Taking dangerous doses of over-the-counter medicines
Douching with poisonous and caustic substances (bleach)
- Younger, unmarried women often have poor access to
Inflicting physical abuse (falling down stairs, blows to belly,
family planning information and services. They also have
jumping from heights)
The Cost to the Public Health System
Treatment of abortion-related complications often requires
In some hospitals in developing countries, treating the com-
several days of hospitalisation and staff time, as well as
plications of unsafe abortion consumes as much as 50% of
blood transfusions, antibiotics, pain control medications and
the total budget.4
other drugs.'
Legislation and Policies on Abortion
Pregnancy termination is permitted in more than 131
Governments around the world have recognised that
developing countries (and almost every developed coun-
unsafe abortion is a major public health issue. At the 1994
try) - either for broad economic or social reasons, or
International Conference on Population and Development,
for more limited health or personal circumstances such as
they called for humane, high quality medical services to
to protect the health of the woman or in case of rape or
prevent unsafe abortion and treat its complications.
incest. Definitions of "health risk" vary widely by country.
Participants also called for safe abortion services where not
against the law."
*The World Health Organization acknowledges that data on unsafe abortion are scarce and subject to substantial error due to methodological
constraints inherent in abortion-related research.
SAFE MOTHERHOOD FACT SHEET
Why Do Women Resort to Abortion?
Most women who decide to terminate a pregnancy are mar-
- Sexual coercion or rape: In studies around the world,
ried or live in stable unions and already have several
between 20% and 50% of women and girls report sexual
children.¹ Women can find themselves with an unwanted
abuse, rape or sexual coercion."
pregnancy for many reasons:
- A variety of social and economic reasons that include:
- Family planning is out of reach: At least 350 million cou-
they are unmarried, have been abandoned by their part-
ples worldwide do not have access to information about
ners, are adolescents, are in an unstable partnership, have
family planning and a full range of modern
too many children to support, and/or live in poverty. 10.11
contraceptives."
- Contraceptive methods fail: Between 8 and 30 million
pregnancies each year are the result of contraceptive
failure- - either inconsistent or incorrect use of family
planning methods, or failure of the methods themselves."
Poor and Unavailable Health Services Make the Problem Worse
Even where legal, abortion is not always available: In many
Family planning is not always offered to women who have
developing countries, health workers, doctors and nurses
been treated for abortion complications In Zambia, for
do not have adequate training or equipment. Some refuse
example, 78% of women treated for abortion complica-
to perform abortions because they do not understand the
tions said they wanted information about family planning;
laws or because they personally do not support abortion.¹⁴
44% wanted to receive a method. However, family plan-
ning was discussed with only 33% of the women, and none
Treatment for unsafe abortion is inadequate: When women
was offered a method to take home."
have complications from an unsafe abortion, good medical
care is often unavailable. Lack of training, equipment and
protocols; misdiagnosis; negative attitudes of health workers;
and/or overcrowded emergency wards can result in life-
threatening and costly delays for women seeking treatment.
What Can Be Done
Ensure universal access to client-sensitive family planning
Offer family planning counselling and services, and refer-
services, especially for young people and women at risk of
rals for comprehensive reproductive health services, to all
sexual abuse, rape and violence.
women who have had an abortion.
Offer safe abortion services by trained, compassionate
Educate communities about reproductive health and
staff when allowed by law;*
unsafe abortion.
Ensure that high-quality services for treating and manag-
Reform laws and policies to support women's reproduc-
ing abortion complications are accessible through the
tive health and improve access to family planning, health
health system.
and abortion-related services.*
*Each of the co-sponsors of the Safe Motherhood Initiative (see below)
implements these activities according to its specific mandate.
Sources:
1: Abortion: A Tabidation of Available Information, 3rd edition. World Health Organization,
10: Expanding Access to Safe Abortion: Key Policy Issues. Population Action International,
Geneva, 1997. in press.
Washington, DC. September 1993.
2: The Health of Young People: A Challenge and " Promise. World Health Organization, Geneva,
11: S.N. Kinoti, et al., Monograph on Complications of Unsafe Abortion in Africa.
1993.
Commonwealth Regional Health Community Secretariat for East. Central and Southern Africa,
3: "Care for Postabortion Complications: Saving Women's Lives". Population Reports. Vol. 24.
Arusha. Tanzania, 1995.
No. 2. September 1997.
12: Proceedings: Abortion Matters. International Conference on Reducing the Need and
4: EM. Coeytaux, "Abortion". in M. Koblinksy, et al., eds., The Health of Women: A Global
Improving the Quality of Abortion Services, Stimezo Nederland, Utrecht. Netherlands, 1997.
Perspective. Westview Press, Oxford, 1993.
Prepared by Family Care International (FCI) and the Safe Motherbood Inter-Agency Group
5: "Abortion Laws Into Action: Implementing Legal Reform". Initiatives in Reproductive Health
(IAG). The IAG includes: the United Nations Children's Fund (UNICEF). United Nations
Policy. Vol. 2, No. I. Ipas, Carrboro, NC. January 1997.
Population Froud (UNFPA). World Bank. World Health Organization (WHO), International
Planned Parenthood Federation (IPPF). and the Population Council: FCI serves as the secretariat.
6: Report of the International Conference on Population and Development. United Nations,
New York, 1994.
These fact sheets have also been prepared III more detailed versions for technical audiences. For
more information or copies of available materials. contact any IAG member, or the secretariat at:
7: N. Sadik, The State of World Population 1997. UNFPA, New York, 1997.
Family Care International
S: S.J. Segal and K.D. LaGuardia, "Termination of Pregnancy A Global View". Bailliere's
588 Broadway. State 503
Clinical Obstetrics and Gynaecology, Vol. 4. No. 2. 235-247. 1990.
New York, NY. 10012. USA
9: Heise, K. Moore, N. Toubia, "Sexual Coercion and Reproductive Health: A Focus on
Tel: (212) 941-5300
Research". Population Council, New York, 1995.
Fax: (212) 941-5563
Email: [email protected]
Web site address: www.safemotherbood.org
1998
is
Measuring Progress
During the last decade, governments around the world have pledged to cut maternal mortality in half by the year
2000*. However, accurate figures on maternal death are difficult to gather. Therefore, countries need other, more
reliable and cost-effective ways to measure their progress toward reducing maternal mortality.
What Is a Maternal Death?
"The death of a woman while pregnant or within 42 days
- A rate: The maternal mortality rate is the number of
of termination of pregnancy, irrespective of the duration
maternal deaths per 100,000 women aged 15-49 per year.
and the site of the pregnancy, from any cause related to or
It reflects both a woman's risk of dying from maternal
aggravated by the pregnancy or its management, but not
death and her risk of becoming pregnant.
from accidental or incidental causes".'
- A "lifetime risk": A woman's lifetime risk of maternal
Maternal death statistics are usually expressed as:
death is the probability that she will die from complica-
tions of pregnancy or childbirth at some point during her
- A ratio: The maternal mortality ratio is the number of
entire reproductive life-span. It is often used to illustrate
maternal deaths per 100,000 live births. It indicates the
the differences in the risk faced by women in developed
risk of maternal death among pregnant women and those
and developing nations.³
who have recently delivered. 2.3
Why Is Maternal Death Difficult to Measure?²
It is under-reported: People in developing countries often
mation is not always recorded. Deaths are sometimes inten-
die outside the health system, which makes accurate
tionally misclassified, especially if they are associated with
registration of deaths difficult. Under-reporting can be sig-
clandestine abortions.
nificant; in some studies, the actual number of maternal
Methods used to calculate maternal death rates are often
dearhs was double or triple what was initially reported.4
complex and costly to use. The acrual number of maternal
It is misclassified: Health workers may not know why a
deaths in a specific place at a specific time is relatively
woman died, or whether she was or had recently been
small. Therefore, very large populations must be surveyed
pregnant. Even if the health worker does know, the infor-
in order to get accurate estimates.
Which Estimates of Maternal Mortality Are We Using Now?
The World Health Organization and UNICEF have
- sensitise policy-makers, programme-planners and others:
developed a new way to estimate maternal mortality that
- stimulate discussion and action; and
compensates for under-reporting and misclassification.
Their estimates, for the year 1990, are generally accepted
- mobilise national and international resources.
for countries without reliable data, but they still have wide
Although these estimates can be used to monitor trends
margins of error. Therefore, they should only be used to
over more than a decade, they cannot provide information
describe the general size of the problem in each country
on short-term progress in reducing maternal mortality.
in order to:¹⁵
What Information Do We Need?
In order to reduce maternal deaths, it is more important to
- Process indicators, such as the proportion of births that
understand why women are dying than to know exactly
are assisted by skilled health personnel or that take place
what the level of maternal mortality is. Such information
in health facilities." Studies have shown that reducing
can be found through:
maternal mortality depends primarily on women's use of
good quality maternal health services.
*Including at the global Safe Motherhood Conference (1987), World Summit for Children (1990), International Conference on Population and
Development (1994), World Summit on Social Development (1995) and Fourth World Conference on Women (1995).
SAFE MOTHERHOOD FACT SHEET
- Case reviews of the causes and circumstances surrounding
EVALUATING OBSTETRIC CARE:
a select number of maternal deaths. There are two types of
In order to reduce maternal mortality, high quality obstetric ser-
reviews: those that focus only on what happened once the
vices must be available to manage major complications. UNICEF,
woman reached the health facility (such as whether the
WHO, and UNFPA have developed a series of process indicators
that focus on these essential obstetric services. Data for these
doctor was available), and those that also investigate what
indicators can be collected and analysed at health facilities with-
happened beforehand (such as whether there was a delay
out large-scale community surveys.'
in reaching the facility in the first place).* These reviews
This series includes indicators that measure:
provide valuable information that can be used to identify
the availability of services;
and address problems, either with the quality of services or
the use of services; and
within communities.
the performance of health facilities.
More information on this series can be found in "Guidelines for Monitoring the
Availability and Use of Obstetric Services", UNICEF, New York, October 1997.
Measuring Maternal Illness and Disability
Pregnancy complications can cause serious, long-term
However, it can be difficult to identify and classify mater-
health problems even when they do not result in death. As
nal illnesses and disabilities. Even trained medical
such, it is important to try to assess the scope and impact
personnel may differ in their diagnoses. As such, experts do
of maternal disabilities, and to understand how they are
not recommend using indicators of maternal morbidity as
perceived and dealt with by women and communities.
an alternative to maternal mortality as a way to measure
the impact of safe motherhood programmes.
What Can Be Done
Decide whether establishing a national maternal mortality
Use findings from maternal mortality studies and
figure is the best use of scarce resources. If an estimate is
programme evaluations widely. Depending on the type
needed to stimulate attention and action, decision-makers
of study, clearly-presented results and recommendations
can use the revised WHO/UNICEF figures to indicate the
for action may be useful to a broad range of audiences,
magnitude of the problem.
including: policy-makers, health providers, hospitals,
medical societies, community groups, and research insti-
Use process indicators to develop, implement and evaluate
tutes. Community involvement can be very helpful both
policies and programmes based on reliable information.
Health planners should be careful to select indicators that
in conducting the studies and identifying and carrying
out solutions based on the findings.
are easy to collect and are most relevant to the activities
being implemented.
Sources:
1: International Classification of Diseases, 10th Revision. World Health Organization. Geneva,
S:J. Ireland and W. Graham. "Conducting a Case Review of Maternal Deaths" Dugald Baird
1992.
Centre for Research on Women's Health, University of Aberdeen, May 1996 (prepared for WHO
2: UNICEF/WHO/UNFPA. "Guidelines for Monitoring the Availability and Use of Obstetric
Safe Motherhood Needs Assessment).
Services". UNICEF New York. October 1997.
Prepared by Family Care International (FCI) and the Safe Motherbood Inter-Agency Group
3: "Revised 1990 Estimates of Maternal Mortality: A New Approach by WHO and UNICEF".
(IAG). The IAG includes: the United Nations Children's Froud (UNICEF). United Nations
World Health Organization, Geneva, April 1996.
Population Fund (UNFPA). World Bank. World Health Organization (WHO). International
Planned Parentbood Federation (IPPF). and the Population Council: FCI serves as the secretariat.
4: H. Atrash, "Maternal Mortality Surveillance". Presentation at the Safe Motherhood Technical
Consultation in Sri Lanka, 18-23 October 1997.
These fact sheets have also been prepared in more detailed versions for technical audiences For
more information or copies of available materials. contact any IAG member, or the secretariat at:
5: O. Campbell, "Measuring Progress in Safe Motherhood". Presentation at the Safe Motherhood
Technical Consultation IN Sri Lanka, 18-23 October 1997.
Family Care International
588 Broadway. Suite 503
6: W. Graham and O. Campbell, "Measuring Maternal Health: Defining the Issues". London
New York, NY. 10012. USA
School of Hygiene and Tropical Medicine, London, May 1991.
Tel: (212) 941-5300
7: "Indicators for Monitoring Maternal Health Goals". World Health Organization, Geneva,
Fax: (212) 941-5563
1994.
Email: [email protected]
Web site address: www.safemotherbood.org
1998
FROM : Beach House
PHONE NO. : 3019510340
Mar. 31 1998 04:06PM P1
03/31/96 TUE 16:10 FAX 202 456 6244
CFC OF THE FIRST LADY
001
CRYPTEK TS-18A
TUE 31 MAR 98 14:54
PG_02
TOCHRISTY Coul- some FIRST LADY Lave
HILLARY RODHAM CLINTON
TALKING IT OVER
MARCH 31, 1998
will
The women my husband and 1 met on our ulp to Africa greeted us with song. They sang
is
of their lives. They sang of their hopes for themselves, their families, and a new Africal They
The Theirs sery of
sang for every generation\ Whether It's speaking out against oppression or calling out for
economic opportunity, the women of Africa have never stopped singing together.
unitin sacsin then
vorses in say.
In Ghana, 1 heard women singing for the chance to become full participants in their
country. They were dressed in aqua, orange, yellow and other bright colors, and all united by 8
common mission. Like the Queen Mother of the Ashanti Stool, who led the Ghanaian people
against outside invaders at the end of the last century. these women are leading their country into
the Millennium They showed me the micro enterprises they've created selling jewelry, art,
clothing, and other goods. But, nothing made them more proud than their day care center.
There, in bright rooms, 1 saw children being nurtured and cared for while their mothers worked to
support their families.
as benet then
iss.
In South Africa, I heard women singing for chance to build a home and a community.
As we approached the Victoria Mxenge Housing Project, we could still see the shanties where a
group of homeless squatters - mostly women - used to live. Now, on the other side of the street,
there is a vibrant community these women have created by pooling their resources, securing small
loans, and building homes together singing all the while
FROM : Beach House
PHONE NO. : 3019510340
Mar. 31 1998 04:06PM P2
03/31/98 TUE 18:11 FAX 202 456 6244
OFC OF THE FIRST LADY
V
002
CRYPTEK TS-10A
TUE 31 MAR 98 14:55
PG.03
2
"Strength, money, and knowledge," they sang to me last year, "we cannot do anything
without them." When my husband joined me at the village last week, we saw the remarkable
changes borne of these three ingredients. [We saw one family's pride as they showed us around
could
their home and shared in others' excitement as we helped lay down the first concrete bricks of
a
cut
new home.]
Last year, I asked the women of Victoria Mxenge if they believed they would own a home
week-
had
new
themselves someday. The answer was a resounding "yes." This time, I asked them how many
become
now
actually owned a home. Hands shot up throughout the group. In just one year, the number of
name-
104
curer
homes in that village has increased from 18 10 19. Roads once made of dirt are now paved.
The concrete slab where we gathered last year is now a community center, complete with a day
care center and a store. And the women have Just bought a whole new plot of land that will
provide fertile soil for new businesses, new homes, and the fulfillment of lifelong dreams.
on they releast
in Rwanda, I heard women singing to rebuild lives ripped apart by genocide. I heard the
women in Uganda as they worked to provide education to every boy and every girl. I heard them
in Botswana, where women leaders were helping to combat the scourge of AIDS and promote
legal rights.
FROM : Beach House
PHONE NO. : 3019510340
Mar. 31 1998 04:07PM P3
03/31/98 TUE 16:11 FAX 202 456 6244
OFC OF THE FIRST LADY
&
003
CRYPTEK TS-18A
TUE 31 MAR 98 14:56
PG B4
3
And in Senegal, I heard women singing for their health and their futures. The
group of women 1 met with from the Malicounda Bambara village, had done something
remarkable. Although female genital mutilation (FGM) only affects up to 20 percent of
women in Senegal, in many villages like Malicounda, it is considered a rite of passage for
14 &
6,ther?
all girls.. What drove them to change all of that? One woman explained that they had
"studied human rights and particularly the right to health"
* # A
These women decided that FGM had harmed their daughters' bodies and spirits for
too long. They decided that it was time to and the hemorrhaging. It was time to end the
diadm
infections, AIDS, and childbirth complications caused by this tradition And that's exactly
what they did.
Using 2 skit they showed me, the women of the Malicounda village educated their
religious leaders, their husbands, and their neighbors. They banned this practice - and
they are-now inspiring others to do the sains. Just last month, 13 villages with a combined
population of more than 8,000 people joined together to end FGM in their communities.
And President Diouf has now called for a new law to abolish It throughout the country.
FROM : Beach House
PHONE NO. : 3019510340
Mar. 31 1998 04:07PM P4
03/31/98 TUE 16:12 FAX 202 456 6244
OFC OF THE FIRST LADY
5.
004
CRYPTEK TS- 100
TUE 31 MAR 98 14:58
PG.05
hi as with own Their success ston
1
Success stories like these are being written throughout Senegal and Africa. In
Thies, I met a group of parents at the Mode Kane School. They were improving their
children's lives by learning to lift up their own education, literacy, and health. And they
(ml)
too were 50.11 singing a song about their journey. It was called Women's Rights: "All
people have equal rights. The right to education. The right to health. These rights have
changed our lives In our homes, in our neighborhoods and in our country."
CMV
With every voice added to this song. the chorus became more powerful. With
every voice added, the aspirations of individuals blended into the dreams of generations
dreams of a pety TOB for women in a new Africa.
As we left Senegal to return home, I thought about how one of that country's
greatest authors, Ousmane Sembere, described 8 group of women from Thies who
marched and sang in the name of simple fairness and prugress. He wrote "Even X since
they left Thies, the women had not stopped singing. As soon as one group allowed the
refrain to die, another picked it up and new verses were born No one was very sure any
longer where the song began, or if it had an ending It rolled out over its own length, like
the movement of a serpent. It was as long as a life."
I
hope
Like women all over the world the women of Africa will never stop singing.
212-941-5563 FAMILY CARE INTL.
725 P01
APR 01 '98 09:20
FAMILY CARE INTERNATIONAL
588 BROADWAY SUITE 503 NEW YORK, NY 10012 [email protected] FAX 212 941 5663 TELEPHONE 212 941 6300
1
merday regist
Pren /caped
bent people
Wednesday, 1 April 1998
3P?
To:
Christy Macy
Emendar ment
From:
Jill Sheffield
FSH 3131 6:30
safe mocher hard
- corporate partner
Dear Christy,
Two diner
public amerint sever
Attached in two pages are some examples of success stories in several of the technical arenas.
But they ALL show that with a little ingenuity and a lot of determination, almost anything is
possible.
One really super success story (I have the article -- if you were to want it) is from Tanzania.
District Hospital with enormously high maternal death rate. Staff decided to find out why and
do something did a complete audit of why each woman died. Compiled a list of what they
could do from moving the physician to the hospital compound in the cleaned, painted (quite
modest) house, dam up a little river for several hours of auto-clave access per week, ordinary,
practical things. They had 22 things on that list. Maternal mortality came down by nearly 40% in
the two years and at a cost of less than $11,000.
musta
June
Hope you are having some luck. Sounds like they had a good day in Botswana -- even some rest.
Can you come on the 7th? I may be down this Friday. Just so you know. And from Sunday,
we'll be staying at the Lombardy Hotel to make things easy.
202- 413
Have a splendid day its a wonderful one in NYC!
MANTA
shepped
4486
Best,
fill
473
3691
X 522-
2653
PS - Success stories are from
the longer varsions of our
fact sheets.
Email
1 shell W family care cry INTL
322- 2653 ( Jab)
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SAFE MOTHERHOOD SUCCESS STORIES
IMPROVING ACCESS TO CARE:
Barriers of distance and lack of transport have been reduced by:
Assigning health workers trained in midwifery to village-based health facilities, backed up by a
functioning referral system. Such a system has been instituted in Matlab, Bangladesh," Sri
Lanka and Cuba, where maternal mortality has declined.
Decentralising care to the lowest level of the health care system that is able to provide it
adequately. In Mozambique, nurses have been trained to perform Caesarean deliveries;
outcomes are as good as for women who had Caesareans performed by specialist obstetricians.¹
Setting up systems for emergency transport and referral of complications. The involvement of
local community members and leaders in designing and implementing these systems is crucial,
as is the support and cooperation of the health system. In Uganda, the "Rescuer" project ensures
that TBAs have radio communication to call for help, and that local transport can be obtained on
short notice. 20 In Sierra Leone and Ghana, community leaders were mobilised to collaborate
with the local transport workers' union to set up a roster of vehicles for emergency
transportation."
Establishing maternity waiting homes close to formal health facilities. Maternity waiting homes
can be useful for women living in remote areas or where transport is especially difficult, as in
mountainous areas. Cuba, Ethiopia and Mongolia are using such homes.²
Providing maternal and infant health services for free and assured through governmental action,
improves access for poor women. Several countries, including Bolivia, South Africa,
Bangladesh and Sri Lanka, have made this commitment.
QUALITY CARE:
A generator and blood bank were installed and an unused operating theatre made functional at a
hospital in Makeni, Sierra Leone. In addition, drugs and supplies were provided through a
revolving fund, all for less than $40,000. The number of women seeking care for obstetric
complications increased by over 200%, and the case fatality rate among those women dropped
from 32% to 5%.
In Guatemala, protocols were developed for regional and departmental hospitals to maintain
optimal levels of care for patients in out-patient clinics, labour and delivery wards, and those
receiving hospital-based postpartum care.
In Ghana, the Ministry of Health has developed clinical management protocols for identifying
and treating pregnancy-related complications at all levels of the health system. The protocols
also set standards for the provision of antenatal care, supervised delivery, postpartum care,
family planning and management of abortion complications.
In South Africa, health providers developed a set of recommendations for improving services,
including more training for staff, providing a wider range of services, ensuring adequate supplies
in all facilities and treating all patients equitably.
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In 1986, Malaysia launched a quality assurance system for hospital care. Hospitals are divided
into two categories those with specialists and those without - and compared on the basis of a
set of clinical indicators. Those with poor performance are required to investigate the reasons
why and take action to improve services. The effect of these measures on quality of care are
monitored by state and national quality assurance committees.
ENSURE SKILLED ATTENDANCE:
Policy-makers, physicians, midwives, nurses and community representatives must work together to
create a supportive environment that enables health workers to provide at least some components of
essential obstetric care. 11
In Lesotho, development of national midwifery protocols was completed by midwives working with
obstetricians. 11
In Ghana, midwives trained in life-saving skills now provide emergency obstetric care which had
previously been provided only by doctors.¹³
In Zimbabwe, where over 30% of deliveries take place without a skilled attendant, the government has
launched a national programme to increase the number of nurses trained in midwifery by 50% - by 60%
in rural areas.
In Ghana, the Ministry of Health has developed clinical management protocols for identifying and
treating pregnancy-related complications at all levels of the health system. Designed for midwives,
nurses, doctors and public health workers, the manual also sets standards for the provision of antenatal
care, supervised delivery, postpartum care, family planning, and management of abortion
complications.15
Remarks by the First Lady
http://www.whitehouse.gov/WH/EOP/F.neralspeeches/1997/unspeeches.html
Remarks by First Lady Hillary Rodham Clinton
United Nations Economic and Social Council
United Nations Plaza
New York, New York
December 10, 1997
Thank you. Mr. President, your excellencies. I welcome this opportunity to be
here as we begin this yearlong commemoration, which is not just a
commemoration of the universality of human rights; it is a celebration of the
United Nations. I am especially pleased that we are able to gather this morning
in the Economic and Social Council, which at its first session in February of
1946, established the Commission on Human Rights.
Forty-nine winters ago the world acknowledged the new common standard for
human dignity, a code for the peoples and governments of the world to live by.
One of the people who labored to create that code was Eleanor Roosevelt, then
the United States representative to the U.N. Commission on Human Rights.
The place was Paris. The delegates who came together to craft the language
hailed from countries as diverse as Lebanon, Chile, France, China, and Ukraine.
The dream was the Universal Declaration of Human Rights, the first
international agreement on the rights of humankind.
Some of humanity S greatest lessons emerge only after the deepest tragedies.
This Declaration took shape in a world ravaged by the horrors of militarism and
fascism. In the wake of the most violent revelations of the depths to which
human beings can dehumanize one another, the world as a whole was ready at
last to agree upon these standards for human rights.
Let me read a passage from that document:
Disregard and contempt for human rights have resulted in
barbarous acts which have outraged the conscience of mankind.
The advent of a world in which human beings shall enjoy freedom
of speech and belief, and freedom from fear and want, have been
proclaimed as the highest aspirations of the common people.
Therefore, the General Assembly proclaims this Universal
Declaration of Human Rights as a common standard of
achievement for all peoples and nations.
The document goes on to state what should be obvious, but too often is not:
All human beings are born free and equal in dignity and rights.
They are endowed with reason and conscience, and should act
toward one another in a spirit of brotherhood.
How radically idealistic an act it was at first for the nations of the world to
subscribe publicly to this Declaration.
That act did not, however, take place in a vacuum. It was a response to evil, and
I use that word deliberately. Those who study the Holocaust know that the
Nazis were able to pursue their crimes precisely because they were able
progressively to constrict the circle of those defined as humans. From the
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moment they came to power, they proceeded step by step to dehumanize,
through laws and propaganda, the mentally ill, the infirm, gypsies,
homosexuals, Jews those whom they identified as life unworthy of life.
This cold, dark region of the human soul, where people withdraw first
understanding, then empathy, and finally even the designation of personhood
from another human being, is not, of course, unique to Nazi Germany. This
device, this ability to dehumanize, has been witnessed in all times and places. It
is precisely this device that the Declaration attempted to help us resist.
Thankfully, in the half-century since the birth of the Declaration, we have, as a
global people, managed progressively to expand the circle of full human
dignity. Because of this document, individuals and nations alike have a
standard by which to measure fundamental rights. Many of the countries that
have emerged in the last 50 years have drawn inspiration from the Declaration
in their own constitutions. Courts of law look to the Declaration. It has laid the
groundwork for the world S war crimes tribunals. It has prompted governments
to set up their own commissions to safeguard basic liberties.
At the United Nations Conference on Human Rights in Vienna in 1993, it was
the power of the Declaration that inspired the establishment of a High
Commissioner on Human Rights. Let me add, how lucky the United Nations
and, indeed, the world is that Mary Robinson fills that post.
At the United Nations Fourth World Conference on Women in 1995, it was the
strength of this Declaration that enabled us to say for all the world to hear that
human rights are women S rights, and that women S rights are human rights.
And yet, in spite of this half-century of progress, we have not expanded the
circle of human dignity far enough. There are still too many of our fellow men
and women excluded from the fundamental rights proclaimed in the
Declaration, too many whom we have hardened our hearts against those whose
human suffering we fail fully to see, to hear, and to feel.
Any look back at history shows that every nation has had its blind spots that
have kept people out of the promised circle of full humanity. Take the example
of my own country. We in the United States have had our own difficult
experiences with the selective or unequal application of the rights established in
the American Constitution. Even the founding fathers, whose ideas of human
dignity were so far ahead of their time, proclaiming that all men are created
equal in the Declaration of Independence, inscribed slavery in our Constitution.
It has taken most of our 220 years, some of them bloody, few of them easy, to
extend the benefits of citizenship to African Americans, to those without
property, and to women. Eleanor Roosevelt herself was 35 years old before she
could vote.
Even today, we circumscribe the circle in what we choose not to see. Black
South Africans described what it was like to work all day in white
environments in which one was literally not seen. In the Balkans, people have
willed themselves not to see the humanity of those whose heritage is different
from their own. We ourselves in the industrialized world often choose not to
see the child labor that goes into our beautiful carpets or our comfortable shoes.
In too many places today what we fail to see are the injustices done to women.
We choose not to see the injustice of legal systems around the world that
continue to treat women as less than complete citizens. In too many places,
female heirs are seeing less inheritance than male heirs. Inequitable divorce
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laws compel women to remain in cruel marriages. And some courts of law
require the testimony of two women to equal that of a solitary man.
Our vision is limited in other areas as well. We choose not to see the
contribution of women to the economic lives of their families and countries. In
too many places, women are discriminated against for bank loans and credit,
first jobs and promotions. They are denied pay equal to that of men, or any pay
at all. They live disproportionately in poverty, making up 70 percent of the
world S poor.
We also circumscribe the circle by what we choose not to hear. Freedom and
equality for all depend first on whether a citizen truly has a voice. It is telling
that even in the drafting of the Universal Declaration, there was a debate about
women S voices. The initial version of the first article stated, All men are
created equal. It took women members of the Commission, led by Hansa Mehta
of India, to point out that all men might be interpreted to exclude women. Only
after long debate was the language changed to say, All human beings are born
free and equal.
Today, we still choose not to hear the voices of many women. In too many
places women are blocked from participating in the political lives of their
countries. Just nine days ago in Sudan, 36 women were arrested while
attempting to deliver a petition to the United Nations office there in protest of
human rights violations in their country. They were arrested, fined, and at least
one woman received 40 lashes.
In too many places girls and women never even learn to project their voices.
Two-thirds of the 130 million school-age children out of school are girls.
Two-thirds of the 96 million people worldwide who can neither read nor write
are women. Even now the Taliban in Afghanistan are blocking girls from
attending school. Not only that, they are blocking those like Emma Bonino, the
European Union Commissioner for Humanitarian Affairs, who would speak out
against this injustice.
Freedom of speech and freedom of the press, the rights to petition the
government and to assemble all these are essential. Just think how much
weaker these rights are in a nation where the majority of young women are
illiterate. Rights on paper that are not protected and implemented are not really
rights at all.
We further constrict the circle of human rights through what we choose not to
feel. As Eleanor Roosevelt put it, When will our conscience grow so tender that
we will act to prevent human misery rather than avenge it?
In too many places, the suffering of women is defined as trivial, explained
away as a cultural phenomenon. Perhaps it is for this reason that women do not
receive proper health care, including access to family planning. Perhaps that is
why, in some countries where more than 90 percent of women have undergone
genital cutting, the practice continues. Perhaps that is why domestic and sexual
violence remains the most serious under-reported and widespread human rights
violation in the world.
In almost every country of the world, domestic violence is one of the leading
causes of injury and death to women. In my country, 30 percent of female
murder victims are killed by current or former partners. As Secretary of State
Madeleine Albright has said, domestic violence can never again be dismissed,
as it often has in the past, as part of a country S norm or as a set of private
assumptions about family life. Let us say it loudly for the entire world to hear
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us: We do not believe that violence against women is simply cultural; we
believe it is simply criminal.
Perhaps that is why rape and sexual assault continue to be tactics of war. It is
the cruelest injustice that so many wars end not in peace for women and their
families, but in refugee crises that trap women and children in lives that go
from bad to worse. Women and children make up 80 percent of the world S 23
million refugees.
The full enfranchisement of the rights of women is unfinished business in this
turbulent century. What meaning does the language of freedom and human
rights have for a young woman forced into prostitution and traffic in the
commercial sex trade? What meaning can it have for women forced into
involuntary servitude as sweat- shop workers or domestic servants? What
meaning can it have for a woman forced either to bear a child or abort one?
What about the very ingrained practices that undermine the growth and
development of girls from their very first years, such as the common practice of
feeding them last or less?
As I have been privileged to travel around the world, I have met countless
women who know nothing of this Declaration and its promises. They are,
however, eloquent in their belief that they deserve respect and better treatment
in their families, workplaces, and societies.
Yet some critics continue to dismiss women S sufferings as minor. But are
they? In 1958 Eleanor Roosevelt wrote:
Where do human rights begin? In small places, close to home, so close and so
small that they cannot be seen on any maps of the world. Yet they are the world
of the individual person the neighborhood he lives in, the factory, farm, or
office where he worked. Such are the places where every man, woman, and
child seeks equal justice, equal opportunity, equal dignity without
discrimination. Unless these rights have meaning there, they have little
meaning anywhere.
Other critics dismiss human rights violations as harmless. A report released this
week by the Carnegie Commission on Preventing Deadly Conflict proves
otherwise. According to the report, an upsurge of egregious human rights
violations is almost always a powerful warning of dire events to come,
including massive refugee flows and civil wars.
Still others say that human rights are a Westerner S luxury not inalienable, but
alien. I believe, and the women I ve listened to believe, that human rights are as
essential to life as air or water, that they are felt beyond culture and tradition as
innate. The women I have met do not feel that human rights are a foreign
concept invented by purists. Rather they know in their very hearts and souls, in
spite of everything they are told by culture and tradition, that these are
God-given rights that they were born with as surely as they were born into the
human family.
For if they are not innate, how have people throughout history known to fight
for them so valiantly? Paradoxically, the proof of universality lies with the
perpetrators of human rights violations themselves. Why would those who have
dishonored humanity run to cover their tracks were it not for the knowledge
that wrong had been done? The Nazis tried to hide their concentration camps.
Communism kept its terrors in the shadow of the Iron Curtain. Scores of bodies
are hidden in the hard ground of places like Bosnia and deep in the forests of
places like Rwanda.
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Throughout my hemisphere, people have disappeared. Why go to the trouble?
Because human rights transcend individual regimes and customs. The beliefs
inscribed in the Universal Declaration of Human Rights were not invented 50
years ago. They are not the work of a single culture or country. They have been
with us forever from civilization S first light.
Sophocles wrote about them 2,500 years ago when he had Antigone declare
that there were ethical laws higher than the laws of even kings. P.C. Chang,
who helped draft the Universal Declaration, pointed out that Confucious
articulated them in ancient China. The belief that we must respect our
neighbors as we would respect ourselves resides in the core of the teachings of
all the major faiths of this world.
The principles inscribed in the document whose birth we mark today are not
constructed, but revealed. Every great religion exposed and taught their truth. If
I were to tear up this declaration, its values would abide. If I were to burn this
document, its meaning would remain. If I were to forbid someone from hearing
its words, they would still ring as loudly as ever in the hearts of men and
women.
It is because every era has its blind spots that we must see to our own
unfinished business with even greater urgency now while we stand on the
threshold of a new millennium. We must rededicate ourselves to completing the
circle of human rights once and for all. We must challenge ourselves to see
more sharply, to hear more clearly, to feel more fully.
And we must do something else. We must support democracies new and old
that work to fulfill the aspirations of this Declaration. As my husband, the
President, said last night: Democracy, the rule of law, civil society those things
are the best guarantees of human rights over the long run.
It is time for us as a global community to commit ourselves. We have run out of
excuses not to. Here we are at the very close of the 20th century, a century that
has been scorched by war time and time again. If the history of this century
teaches us anything, it is that whenever the dignity of any individual or group is
compromised by the derogation of who they are, of some essential attribute
they possess, then we all leave ourselves open to nightmares to come.
Conversely, if the century has a lesson for us that is redeeming, it is that by
extending the circle of citizenship and human dignity to include everyone
without exception, then we have the basis where new worlds of hope can
flourish.
So, let us in this year of commemoration walk toward those new worlds. Let us
do so knowing that the path will never be easy. These rights may be eternal, but
so too is the struggle to attain them. Though the darkness of the human heart
may recede, it will never go away. It must be with realistic eyes that we look
for human rights. And it must be with open hearts that in this, the 50th
anniversary of the Universal Declaration on Human Rights, we rededicate
ourselves to its fulfillment.
Thank you very much.
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THE WHITE HOUSE
Office of the Press Secretary
FIRST LADY HILLARY RODHAM CLINTON
REMARKS TO THE WOMEN OF ARGENTINA
COLON THEATER
BUENOS AIRES, ARGENTINA
October 16, 1997
Thank you, Mrs. Schiavoni.
To all of you -- Ambassadors, Ministers, Representatives, of the federal and local
government, academicians, business women, homemakers, artists, teachers -- to all of you, I
thank you for this opportunity to speak before you today. I would like to exte nd a special
thanks to the staff of the United States Embassy, but particularly to the National Council of
Women and their staff for the outstanding work that was done to make this gathering
possible, and I believe we should show appreciation to Mrs. Schi avoni and all associated
with the National Council of Women by another round of applause. Thank you.
I also understand I should give a special greeting to all the mothers in the audience, on the
eve of Mother's Day, and I do so.
I am, as you may know, an empty-nest mother now, and I called my daughter last night to
tell her that I had seen just a small sample of tango, because she loves dance of all forms
and wrote a paper in Latin American history on tango and its origins, so I was so pleased to
be able to tell her what my husband and I had done on our first night together here in this
beautiful city.
I must confess that it is somewhat awe-inspiring to be in this magnificent theater on a stage
that has been graced by Domingo and Carusso and Callas. I am almost tempted to sing, but
in the interest of preserving warm ties between our countries, I will refrain.
But I would like to talk about voices, powerful voices, the voices of women in this country
and my country, throughout our hemisphere and our world, and what we can do to make all
of our voices heard. To have our voices heard about our shared commitment to advancing
the cause of women's rights, advancing the cause of democracy, and making clear that the
two are inseparable.
I can think of no better place to do that than in Argentina. The women of Argentina have
long been pioneers on the frontiers of human rights and equality.
From the Argentine Beneficent Society to the National Women's Council to the
Grandmothers of the Plaza de Mayo -- with whom I will meet shortly, you and your
foremothers have forged a remarkable record of speaking up in your communities, caring
for those who cannot help themselves, opening the doors of education to boys and girls,
lifting up lives and voices for democracy and human rights.
We are pursuing our goals of equality at a moment in history that is full of hope, a time ripe
for positive social change. Countries that were once paralyzed by debt or runaway inflation
have embarked on tough reforms and are now on the move.
Economic renewal has been accompanied by democratic transformation. Across the
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Americas, military dictatorships have given way to freely elected governments. For the first
time in decades millions of people enjoy the right to choose their own leaders, t o engage
actively in political life, to speak frankly, to meet in support or opposition to a cause, and to
form opinions based on information gathered by a free and inquiring press.
Yet we know that democracy, whether newly rooted or centuries old, is fragile. The process
of building and tending democracy is ongoing. Democracy flourishes when its principles are
internalized in the hearts and minds of all people, when no one fears t he consequences of
standing up or speaking out for justice. And democracy thrives when women are not barred
by law, by ignorance, by tradition or by intimidation from making their voices heard at the
ballot box, and from pursuing their most cherished dre ams.
In short, empowering ever-more women to seek and claim their rights as citizens and as
human beings will ensure that democracies -- yours and mine, old and new -- survive and
thrive in the twenty-first century.
The word "empowerment," I am told, does not translate well. But I am sure that every
woman gathered here knows its meaning. Empowerment means the right to participate in
the political and economic life of our countries. Empowerment means being able to lead
lives free of sexual and domestic violence. It means access to justice under law, to
education, to health care, to credit and property ownership.
Empowering women makes sure our voices are heard and we are treated as full citizens in
our countries.
No nation can hope to succeed in our global economy if half of its people lack the
opportunity and the right to make the most of their God-given promise. And, as we can all
attest, in too many countries, my own as well, too many rights are still denied a nd too many
doors of opportunity still remain tightly closed.
Too many women and children are trapped either in an endless cycle of poverty -- a cycle
perpetuated by inadequate health care, poor access to family planning, and limited education
-- or they are trapped inside social constructs that impoverish their spi rits and limit their
dreams.
Too many women are unable to participate in the economic lives of their countries because
they cannot get credit on their own to start small businesses.
Too many women live in fear of violence at the hands of family members. For them, home
provides no refuge, the law no protection, and public opinion no sympathy.
Too many women, especially those who are poor and less educated, are unaware of their
legal rights in the workplace, of their rights to own and inherit property, of their rights to
vote and choose their leaders. While these laws may exist on the books, t 00 many
governments have not enforced them and too few women have been made aware of them.
Such problems as these may be daunting, but their solutions are in full view. Across the
Americas, from Boston to Buenos Aires, there are cutting-edge, common-sense initiatives to
give girls and women access to what I call the tools of opportunity: educa tion, decent
health care, legal protections, and credit. These efforts prove that women can be empowered
to lift themselves, their children, families, and communities out of poverty.
Let me begin with education, for nothing outside the family is more central to advancing the
cause of girls and women. And Argentina has long recognized that fact.
Our two nations have a history of warm ties. One of the most notable was the friendship
between Horace Mann, the father of public education in the United States, and President
Domingo Sarmiento, the father of education in Argentina, who was ahead of his time with
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his deeply held belief that girls should attend school.
The fruits of his conviction are there for the world to see today: In Argentina's strong and
established system of education. In a literacy rate of 96 percent. And in a primary school
completion rate of 90 percent.
Other countries in the Americas are rededicating themselves to improving access to and the
quality of education for all their citizens as you have long done. Education will be the
centerpiece of the Second Summit of the Americas in Santiago next April, a nd it will
highlight models that are working.
Yesterday in Sao Paulo, for example, I saw an elementary school in one of the city's poorest
neighborhoods. For years, the school struggled. Many students were not learning and most
did not stay in school. Fortunately, the business community, recogniz ing the importance of
education, got involved, and created the Institute for Quality Education. Working with the
local government, parents, and teachers, they have transformed the school. Teachers who
themselves may not have finished high school have no W received additional training.
Students were tested. Parents were encouraged to get involved. In less than a year, test
scores in mathematics and language went up more than 200 percent. Even in countries like
ours, Argentina and the United States whe re we don't face such daunting challenges as
Brazil does, we have to do more to improve the quality of education in both urban and rural
areas and to ensure that all students have access to information technology. Concentrating
on education and insuring that all the children of the hemisphere have a chance to learn will
be the most important way that we can enable all of our economies to grow and flourish.
And an economy that grows and flourishes in Argentina or in the United States is good for
their citizens and for other neighboring countries' citizens. But if we can create the capital of
education in all the other countries in the hemisphere, that too i S good for Argentina and the
United States.
Another tool of opportunity is Microenterprise. Microenterprise provides small loans to
people, mostly women, who would not otherwise receive them. This concept started in Asia
about 20 years ago when it was determined that a very small amount of money given to a
hard-working woman who might be landless and totally ignorant, but she had skills that
were marketable she knew how to sew, she knew how to plant crops, she could do things
with a little bit of credit that could bring income into her f amily.
I have seen all over the world how access to such credit sparks a woman's entrepenurial
spirit. Just in the last week I have seen two more examples here in our own hemisphere. In
Panama I visited a group of women who, with a small grant from the United States Agency
for International Development, started a business in a small village growing plants and
seedlings to sell in city markets and also to sell to the Panamanian government's
reforestation programs.
Now here is something that women have known for the millennia how to tend and nurture
plant life. Women have held the secrets of medicinal plants and herbs. There are so many
women throughout this hemisphere with those kinds of skills. To create a m arket for their
product gives them a chance to use their skills to earn income to improve the standard of
living of their families, and that is what I saw. Within two years, these women had sold
enough orchids, medicinal plants and seedlings to expand t heir business. They had also
furnished enough seedlings to restore 48 acres in one of Panama's national parks; and I
talked with women who were using their new income to improve their homes and send their
children to school.
I met an equally impressive group of women in Caracas. I entered an ordinary-looking
building in one of what I was told to be one of the worst neighborhoods in Caracas. And
yet, in this very well-kept space, sitting on an open-air, rooftop terrace, talk ing with these
women, I was very moved and impressed. The walls were adorned with weavings and art
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works that they had made. As a light breeze blew in, one woman told me how she had
started a thriving taxi company. She knew how to drive, she was respo nsible and
hard-working, there was no transportation adequate to the numbers of people in her
community, so she had this idea but no one would give her the credit to purchase the van
that she needed until she came to this Microenterprise Institute. She S aid that when she
finally got her own business, it was as if "the sky had opened up."
Another woman used a small loan to expand her juice stand that she ran with her husband.
Then a few years later she had a restaurant and a butcher shop employing ten people. She
had even been able to send one of her children to university -- a woman who had never
finished primary school. She said the loan had given her the opportunity "to spread her
wings."
Now these are not unique stories. I have met similar women in Nicaragua and Costa Rica, in
Bolivia and Chile and Mexico, and I know they are here in Argentina and in my country as
well.
Because a real job is the best form of social welfare, microenterprise works for the
individual, the family, and society. And the more we can expand credit, to both women and
men who appear on the surface to have no collateral, to be poor, but who have S kills that
keep them going every day in the hard lives that they face, the more we will create free and
broader markets that will enhance the economies of our countries.
Access to quality health care -- especially family planning and reproductive health services
-- is also crucial to advancing the progress of women. I have seen first-hand, as I know
many of you have, what happens when women are given access to such healt h services.
Just two days ago in Brazil, I witnessed the signing of an agreement between my
government and two Brazilian state governments to support a family planning initiative.
This came about because two years ago I visited a maternity hospital in Salvador de Bahia,
Brazil, and I saw men and women getting the information they would need to enable them
to make wise choices about planning their families. I saw mothers cradling their new-born
babies in the hallways as they stood in line for their check-ups. I S aw young women, very
pregnant, waiting for their pre-natal check-up. I saw infants were getting immunization. I
saw parents were being taught what to feed their young children and how to care for them.
And I also saw wards of women who were there becau se they had not received good quality
health care.
In short, family planning and reproductive health programs were integrated in that hospital
into maternal and child health services. And I talked with a number of mothers, as well as
with the Minister of Health, who told me that for the first time they felt they could
adequately care for the children they had, that they could invest in those children not only
their love but other resources as well.
The result of a program like that was that rates of maternal mortality and, importantly, rates
of abortion decreased because women received the health care they needed in a timely
manner and furthermore, as the Minister of Health, an esteemed medical doct or and
university professor, told me, for the first time poor women received the same health
services that rich women have always been able to receive for themselves.
This approach of integrating the services and reaching out to poor women and men has
proven so successful that it has been adopted as a hemisphere-wide strategy to reduce
maternal mortality, and was announced at the First Ladies of the Americas Conference in La
Paz last year.
Now the promotion and expansion of women's legal and political rights may, perhaps, be
the most difficult challenge we face. And yet slowly but surely we are witnessing the
emergence of legal reforms that will raise the status of women in the home and in society.
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Domestic and sexual violence against women remains one of the most serious and
under-reported human rights violations in the Americas. In country after country, we are
finally bringing out into the light of day what has been thought to be a private matte r. In
Argentina, women have worked to incorporate domestic abuse issues in police training, and
I applaud you. Many countries now have human rights ombudsmen with special offices
dedicated to protecting the rights of women. In Panama, legislators ha ve reformed the
Family Code to better regulate such matters as alimony, child support and child custody.
And in the United States, we have introduced comprehensive violence against women plans
that provide counseling for victims, training for police officers, and prosecution of offenders
in all 50 states.
Throughout Latin America, countries are finding ways to open up political participation for
women at all levels, from the grassroots to the voting booth, and I understand that there are
record numbers of women running for political office here in Argentin a, and I know what a
difficult choice that is to put yourself into the electoral system, and I congratulate all the
women who are standing for public office or who hold public office because of the courage
it takes to do so.
As more women hold office, we have to show that we care about the issues that brought us
into the political process. That is especially critical when it comes to human rights.
At the conference in Panama City, I witnessed the signing of another agreement -- this one
between USAID and the Inter-American Institute for Human Rights in Costa Rica. The
Institute was founded to defend and foster respect for human rights at a time wh en
repressive regimes controlled the lives of many people in the Americas. It offered crucial
support to brave individuals throughout the region who spoke out against torture and
repression at a time when such acts often meant risking one's job, one's ho me even one's
life.
In 1990, the Institute embarked on a new mission in human rights advocacy: It established a
formal program on gender and human rights. When I visited the Institute with Secretary of
State Madeleine Albright in May, I had the opportunity to meet and spea k with women who
are in the forefront of women's rights issues throughout the Americas. As they said, there is
little difference in a woman's life between violence in politics and violence at home. Both
dishonor democracy and respect for the God-given i ndividual dignity of each human being.
As the Secretary of State said on that occasion, domestic violence can never be excused as
cultural. It is criminal and should be treated as such.
There are many examples that I could give you, and you could give me so many more of
what you have seen happening in your own lives, in families, in workplaces, in communities
and countries. But I have seen, as you have, how efforts such as these in educ ation and
health care and credit and in human rights are transforming lives. None of this progress
would have happened if women themselves had not spoken out, demanded change, and
forced their governments to respond.
Now we must encourage more women to make their voices heard, to join together in both
community and national organizations, to press for political change beneficial to all women,
to encourage women to vote in local and national elections, to make politics relevant to the
lives of women, to send more women into political office.
Only women can make democracy work for ourselves, our children and our families. It is a
message that is coming alive throughout the world. Last summer, at a conference in Vienna,
Austria, I met with a group of women from the newly democratic countries of Eastern and
Central Europe. They had just begun to recognize the power of independent citizen action to
address challenges, and they had gathered to share ideas, to renew and strengthen their faith
in democratic values and freedoms.
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This kind of convening might be beneficial for our hemisphere as well. As our countries
continue to expand our political, economic and strategic alliances, as my husband today is
speaking with your President about, the women of this hemisphere can lead t he way in
building an alliance of democratic values that will strengthen our democracies into the next
millennium.
Now many of the issues that are faced throughout the hemisphere and the world may seem
far away from the lives of women here and in the United States. Because in many ways,
women of Argentina and the United States have a wider spectrum of opportunities t han the
women and girls who live in the countries that lie between our own. I was reading in
President Sarmiento's book, Life of the Argentine Republic, and I saw this quote which
described the lives not just of women in Argentina at the time it was written but of women
generally throughout the world, and still describes the lives of most women living on earth
today.
Here is what he said: "Women look after the house, get the meals ready, shear the sheep,
milk the cows, make the cheese, and weave the coarse cloth used for garments The boys
exercise their strength and amuse themselves With early manhood comes com plete
idleness and ease."
Now I am sure the men in the audience would object to that description, but it is not mine. It
is President Sarmiento's. And I am sure that none of us would describe our early adulthood
as ones of "idleness and ease" in today's fast paced world, but th e point is still valid that
there are too many women whose horizons are very limited, but there are many women like
ourselves whose horizons seem to be limitless and yet we, too, face formidable challenges
in our own lives and the life of our societies.
I believe we have a responsibility to work on behalf of women who still struggle for the
rights we have won. But we also must confront the new question that has edged up to our
own front doors.
While the superficial homogenization of the world means that people on every continent
wear the same jeans, eat the same fast food, listen to the same music these surface
similarities do not override a longing for a deeper identity and meaning in our 1 ives.
Despite improving material conditions around the world, many people are not satisfied and
families are under new stresses. The gap between the rich and poor grows wider in many
places. The social safety net of health care, education, pensions, de cent wages, good jobs
is in danger of fraying for those less able to navigate this new world. And even for those of
us blessed with good health, education, and affluence, we also ask ourselves many questions
about the meaning of our own lives.
Questions about how we strike the right balance among our personal roles as wife, mother,
homemaker, employed worker, citizen; about how we claim a personal identity in an age of
anonymous globalization and high technology; about how families will raise c hildren in the
face of pressures from the consumer culture and mass media that undermine parental
authority and glorify instant gratification.
This last question is of particular importance to those of us who are mothers concerned
about the future of our daughters.
For we have not won our places in society, we have not fought for women's rights to make
the choices that are best for them, to stand by while the consumer culture does its best in
my country and yours -- to objectify women and make girls believe that only their
appearances, not their hearts, their minds or their souls, are important.
All the material possessions in the world cannot substitute for a rich and deep spiritual life;
all the affluence in my country or yours cannot answer the eternal questions that are posed
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by every generation. We cannot permit the pace of our life today, the use of automation and
technology, to substitute for what is most important-- the human connections and
relationships that are the stuff of what life is made and which are so essential to creating
those habits of the heart that every child needs to bel ieve in themselves, to have the
confidence to be able to do what they know is right.
This is difficult against the backdrop of this fast paced world in which we live. And I know
that life is changing sometimes faster before our eyes than we can even make sense of. But
we cannot leave the raising of our children, the inculcating of value S to the mass media and
the consumer culture. We have to do a better job through our churches, our families, our
civic associations; we have to build up civil society to reach out to all young people to help
them understand why so many of you have fought so long and so hard for the values, the
rights and the privileges that now in my country can be too easily taken for granted.
Democracy cannot survive unless those values are passed on to the next generation and one
of the values has to be that a woman's full humanity is an unshakable, God-given truth, and
that democracy itself cannot be fulfilled unless women are treated with d ignity and respect.
Last year, I participated in a call-in show on the radio for the Voice of America which went
all over the world. One male caller asked me very earnestly what I meant when I said,
"Women's rights are human rights and human rights are women's rights" at th e Beijing
Conference on Women.
I told the caller to close his eyes and think of all the rights and privileges he enjoyed as a
man. Then I asked him to imagine a world where every woman enjoyed those same rights.
The right to make the choices that fit with that woman's conception of h er future. That
means that a woman may choose to be a full-time wife and homemaker and it is a choice
worthy of respect. That means that a woman may choose to give herself fully to a
professional or business or artistic profession that means she does no t have a place she
believes in her life for marriage or children.
That too, should be respected. And for the vast majority of us who attempt to balance our
commitment to family with an interest in the outside world and a profession that we care
about -- that too should be respected. There should no longer be "one size fits all"
prescription for the way a woman's life should be lived. And because we are fortunate to be
women at the end of this century with many more years than our grandmothers and
great-grandmothers ever could have dreamed, we will have many opportunit ies in our
lifetimes to fulfill our various dreams and aspirations.
The acoustics in this hall are famous throughout the world. So what is said here perhaps can
carry throughout this hemisphere and beyond if we raise our voices on behalf of women to
proclaim that we will not rest until we have repealed discriminatory law S, expelled the
mythology about a woman's proper and only role, stared down the forces of physical and
psychological intimidation that stifle the potential of women and children, and gives full
flower to the belief that a woman has the opportunity and the God-given right to chart her
own destiny, and then to work together to provide the tools of opportunity so that every girl
and boy in this hemisphere can look with confidence toward the future. That should be our
promise to our children for the next cen tury. They, in many ways face, a more difficult life
than we did. It does not seem as clear and set as to what direction many of them should take.
We have to stand with them and with each other as we create conditions that give each a
chance to stand b efore anyone and say "I am a free person, I believe in democracy, and I
believe in building a better world for those who come after."
Thank you all very much.
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212-941-5563 FAMILY CARE INTL.
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FAMILY CARE INTERNATIONAL
588 BROADWAY SUITE 503 New YORK, NY 10012 [email protected] Fax 212 841 5563 TELEPHONE 212 941 5300
Saturday, 4 April 1998
To:
Christy Macy
From:
Jill Sheffield
Dear Christy,
I know that you are working on THE speech
* Bottom of p. 2..."A few years ago, I toured " The group that developed that Safe Home
Delivery Kit is a group called PATH. They are for sure going to be in the audience so it
would be really a good idea to list them in the USAID, Save list of partners.
*Page 4 Para that begins "Think about it..." World Bank estimates that by spending $2 not
under $2.
That's it. I know you are cutting but in case these stay in
Looking forward to seeing you Monday p.m. Going to be GREAT. So many thanks!!
Best,
fill
HILLARY RODHAM CLINTON
SAFE MOTHERHOOD: WORLD HEALTH DAY
THE WORLD BANK
APRIL 7, 1998
It's a great honor and pleasure to be back here at the World
Bank, and to join James Wolfensohn and all of you as we celebrate
World Health Day and recommit ourselves to the global mission
of Safe Motherhood. Thank you for giving me this opportunity to
speak about a subject so close to my heart and of such
extraordinary significance to the future of our world.
I want to thank James Wolfenson for being such a powerful
voice within the World Bank and throughout the globe on behalf of
women, especially his work in raising public awareness that
investments in women and girls are the single most important
investments nations can make to ensure sustained economic
progress and social stability.
I'm so pleased to be joined today by Dr. Crispus Kiyonga,
the minister of Health in Uganda, where I have just visited
and Dr. Siti Hasmah Mohd the first lady of Malaysia. Deep
appreciation also to the leaders of the Safe Motherhood
InterAgency Group - - the World Health Organization, UNFRA (UN
Population Fund), UNICEF, the World Bank, International Planned
Parenthood Federation, and the Population Council who, with
the support of Family Care International, lead critical efforts
to promote the health and well being of women, children, and
families.
I would also like to acknowledge the extraordinary work of
the tens of thousands of foot soldiers on the front lines the
doctors, nurses, midwives and public health workers who are
struggling to meet the often overwhelming health needs of women
throughout the world - - and who, against formidable odds, save
the lives of so many women and children every day. We owe all of
them our deepest gratitude.
We are joined here, on World Health Day, by people in cities
and communities around the globe, who, like us, are raising our
voices in a united chorus to say: no woman should ever die in
childbirth. And that all of us governments, international
agencies, NGOs, and communities have a critical role to play
in saving their lives, and the lives of their children.
We come together this morning at a time of great promise and
hope. I've just returned from an historic trip with my husband
to Sub Sahara Africa, and I wish all of you could have joined us
to see this great country, not only its pro blems, which are
still profound, but the energy and intelligence and determination
of the people. Over the past few years, more than 20 nations have
broken the chains of authoritarian rule, and begun their journeys
toward economic and social recovery.
Yet in the midst of this time of growth and promise around
the world, we still fail to protect our most important citizens -
- the mothers of our children. The numbers are shocking, no
matter how often you hear them. Every minute, somewhere in the
world, a woman dies from complications of pregnancy and
childbirth. Every minute, 190 women face an unplanned or
unwanted pregnancy; every minute, 110 women experience a
pregnancy related complication, and every minute, 40 women have
an abortion.
The tragedy that over 600, 000 women die every year in
childbirth is compounded by the simple yet unbearable truth that
the vast majority of those deaths and so much of that
suffering could have been avoided. The other stark truth that
we continue to face today: Maternal mortality is 150 to 200 times
greater in poorer nations than in our rich ones. And those
deaths are directly related to the high level of poverty, and the
low status of women, in those countries.
Ten years ago, many of the individuals and agencies here
today launched the global Safe Motherhood Initiative, and for the
first time, elevated maternal mortality to an international
priority. And while many countries, including my own, have not
yet met the collective goal of cutting maternal deaths by half by
the year 2000, we should all take pride in the strides we are
making.
The signs of progress are all around us. In Bangladesh, Sri
Lanka, and health workers trained in midwifery are being
assigned to village-based health facilities, and maternal
mortality has declined. In Ethiopia and Mongolia, women living
in remote areas where transportation is difficult can now go to
maternity waiting homes, and get much needed interim care. Last
year, I visited health care clinics in Bolivia, where prenatal
and family planning services have resulted in safer pregnancies
and deliveries, and in some cases, have saved lives.
A few years ago, I toured a small health and family planning
clinic in Kathmandu, Nepal, financed by a partnership with USAID,
the Save the Children Foundation, and the government. And while
I was there, I was given a "Safe Home Delivery Kit" like the
one I have here today that is given to expectant mothers.
Inside is a bar of soap, twine, wax, a plastic sheet, and a razor
blade. It's purpose is to reduce the two major causes of
maternal and neonatal death, tetanus and sepsis, by promoting the
"three cleans" " principle: clean hands, clean surface, clean
umbilical care. The kit was developed by a group called PATH
who I believe is in the audience here today.
Blue
in
as
fa
the
participate
This kit symbolizes for me some of the most important
lessons we have absorbed over the past few years First, we've
learned the power of partnerships. In community after community,
governments voluntary agencies, and local leaders are joining
forces and resources to develop health care strategies that
promote safe motherhood. I was proud to be present at the
in the
launching of one of those partnerships in Bolivia a few years
ago, when USAID and the Pan American Health Organization and
others joined forces to reduce maternal mortality throughout the
hemisphere. shin Loch plue a the (Con agthe cinnerl meeting
9 the first Jadys
We now know, more than ever, that reducing maternal
9th
mortality requires sustained, long term commitments from the full
range of partners. I know that last night there was an important
Howsphere.
meeting of new partners in the corporate sector who are joining
the World Bank and this Safe Motherhood campaign, and I join all
of you in applauding their participation.
But just as importantly, we've also learned that the cost of
promoting safe motherhood is often minimal in comparison to the
extraordinary rewards in saved lives, improved maternal and child
health, and revitalized communities.
Think about it. The World Bank estimates that by spending
$2 a year per person for maternal health care, almost all of the
600,000 women who die as a result of complications during
pregnancy and childbirth would be alive today. And the lives of
2 million infants would be saved.
We have the resources. We have strategies that work. But
we do not yet have the collective will to do what needs to be
done. The result is that today, women in every nation in the
world including my own lack basic health care that could
save their lives and ensure their health. More attention must be
paid to ensure women receive adequate prenatal care, good
nutrition, and quality obstetric care, SO that childbearing and
childbirth is a safe and healthy period of every women's life.
We must invest in family planning which improves maternal
health. Without it, women often turn in desperation to illegal,
unsafe abortion procedures that can account for up to half or
more of all maternal deaths.
But women can't make progress in either their social or
economic status unless they have other opportunities open to them
as well. Education is inextricably tied to how women and
children achieve progress. We've seen how investments in
education have a profound and concrete affect on women's health,
as well as the prosperity of their families and their country.
So do investments in jobs and credit. I've seen how women's
lives have been transformed, and how they've helped lift their
families out of poverty, with just a modest loan to start up a
small local enterprise. But perhaps most importantly, women must
be empowered to participate fully in the decision making and
political life of their countries. Democracy requires the active
Brogil
laurena 5
verm
Carteffeeline
participation of all citizens, including women.
These are the basic building blocks for a healthy and
productive life. These are also the building blocks for social
and economic progress, and the spread of democracy around the
world.
Three years ago, when I addressed the Women's Conference in
Beijing, I said that women's rights are human rights, and human
rights are women's rights. The right to health care is a
fundamental right for all women. Yet that right is violated
every time a woman is denied skilled health workers during
childbirth; every time a woman is denied the right to plan her
own family; and every time she is subjected to violence in her
own home. That basic right is violated every time women are
denied the education and the economic opportunities they need to
ensure they and their children can lead healthy, productive, and
engaged lives.
When this level of social injustice remains commonplace
around the world, then the potential of the human family to
create a peaceful, prosperous, democratic world will not be
realized. But if we can apply the force of international human
rights treaties and national constitutions to ensure mothers and
children are safe healthy, then, and only then, can every woman
be treated with dignity and respect, every child be loved and
cared for, and every family have a healthy and strong future. And
then, and only then, will communities thrive, and nations
flourish.
I want to conclude my remarks this morning with a story from
my recent trip to Africa. That trip was an extraordinary
opportunity for me and my husband to see the flowers of progress
and democracy take root in even the smallest village, nurtured by
the songs and the power of women.
In Senegal, a group of women I met with in the Malicounda
Biambara village have done something remarkable. They have
decided that female circumcision considered a rite of passage
for all girls had harmed their daughters bodies and spirits
for too long. It was time to end the hemorrhaging, and the
infection, and the AIDS, and the childbirth complications caused
by this deadly tradition. And that's what they have done.
Using a skit that they showed me, these women educated their
religious leaders, their husbands, and their neighbors. And as a
result, they have banned the practice of female circumcision in
their village, and now in 13 other villages as well. (I should
note that in some Senegalese villages, this practice affects
about 20% of the girls but in some countries like Mali and
Eretria that figure is as high as 90%).
When I asked one of the women in this small village what had
driven her and others to try to end such a long standing cultural
practice, she replied simply: "We studied human rights, and
particularly the right to health. 11
Thanks in large part to the work of so many of you here
today, this Senegalese women and so many others around the world
now understand that they have a fundamental right to a healthy
family, and a better life. Let's renew our VOW here during World
Health Day - - drawing inspiration and strength from our partners
around the world -- to work together to guarantee every woman
gains that opportunity for herself and her family. For in doing
so, we will fulfill the great promise of prosperity and progress
for all people, and for all nations.
212-941-5563 FAMILY CARE INTL.
647 P01
MAR 25 '98 16:22
facsimile
TRANSMITTAL
to:
Christy Macy
fax #:
202-456-5709
re:
Safe Motherhood speech
date:
March 25, 1998
pages:
13, including this cover sheet.
As per your phone conversation with Jill Sheffield, attached please find some information on the
Safe Motherhood Initiative in general and on World Health Day, specifically. Jill will speak
with you again this Friday.
Please call me if you need any additional materials.
Thanks,
Lill Shappeed
Realarin
cevent -
?
also has
82281
Lanbarde
Ran
1107
From the desk of
1-3
Caryn Levitt
Program Associate
Family Care International
atnen
588 Broadway, #503
New York, NY 10012, USA
Aunhe
473-
212-941-5300
Fax: 212-941-5563
4486
3691
10 Themes of Safe
World Health Day 1998
World Health Day
Advisory Committee
Motherhood
American Association for the Advancement of Science
American Association for World Health
American College of Nurse-Midwives
1. EMpower women
American College of Obstecricians and Gynecologists
American Public Health Association
Invest in the Future:
Association of Maternal and Child Health Programs
Association of State and Territorial Health Officials
Association of Women's Health, Obstetric and Neonatal Nurses
Centers for Disease Control and Prevention (CDC)
2.
KnOw that every pregnancy carries risk
City MatCH
Columbia School of Public Health
Congress of National Black Churches
Family Care International
Family Health International
3. Reduce T eenage pregnancy
Health Resources and Services Administration
Institute of Medicine
March of Dimes
Maternity Center Association
4. Guarantee as a Human right
National Association of Local Boards of Health
National Coalition of Hispanic Health and Human Services Organizations
National Council of La Rara
National Institute of Child Health and Human Development
Pan American Health Organization
E
212-941-5563 FAMILY CARE INTL.
National Association of Childbearing Centers
National Association of County and City Health Officials
5. Reduce unintended pr Egnancy & induced abortion
Population Council
San Diego State University Graduate School of Public Health
Society for Public Health Education
Special Supplemental Nutrition Program for Women, Infants and Children
United Nations Children's Fund
6. Improve access to quality mate Rnal health services
U.S. Agency for International Development
U.S. Conference of Mayors
World Bank
World Health Organization
World Health Organization Collaborating Center in Perinatal Care
Support
Wyech-Lederle Vaccines and Pediatrics
7. Utilize He power of partnerships
Yale University School of Medicine
Safe Motherhood
647 P02
American Association for World Health
ASTOCIATION
FOR
1823 K Street, NW, Suite 1208
8. Measure pr Ogress
Washington, DC 20006
WORLD
202-466-5883 202-466-5896 (fax)
[email protected]
AMBRICAN
www.aawhworldhealth.org
AAWH
April 7, 1998
The American Association for World Health (AAWH) was founded
9. Make a social & ec nomic investment
in 1953 as an educational and charitable non-governmental, non-
profit membership organization. It serves as a voice of opinion to
sustain United States participation in solving international health
problems through governmental and voluntary channels. AAWH
serves as the U.S. committee to the World Health Organization
MAR 25 '98 16:23
10. Ensure supportive care at Delivery
based in Geneva, Switzerland, and its western hemisphere affiliate,
the Pan American Health Organization, based in Washington, D.C.
American Association for World Health
World Health Day
Invest in the Future:
Facts to Know
Support Safe Motherhood
What and When is World Health Day?
Half of all U.S. pregnancies are unintended.
This international initiative is celebrated every
The American Association for World Health in
year on April 7 to promote a forum for informa-
conjunction with the World Health Day Advisory
More than 80% of teen pregnancies are unin-
tended.
Committee has selected the theme "Invest in
tion and discussion about health conditions world-
wide.
the Future: Support Safe Motherhood" to
In the United States, two to four women die
promote World Health Day 1998 in the United
States. In the United States, in nearly two out of
every day from pregnancy-related complications.
Where is World Health Day?
every five deliveries, the woman experiences a
Sexually transmitted diseases greatly
Everywhere. World Health Day is observed in the
complication such as high blood pressure, seri-
increase the risk for ectopic pregnancies.
World Health Organization's 191 member countries.
ous lacerations, obstructed labor, hemorrhage,
uterine infection, diabetes or Cesarean delivery,
The incidence of ectopic pregnancies has
and every day two to (our women die from preg-
Why is World Health Day observed?
increased dramatically-to more than
nancy-related complications.
100,000 per year.
212-941-5563 FAMILY CARE INTL.
The purpose of World Health Day is to encour-
age people around the world to think globally
Maternal Complications
An expectant mother with no prenatal care
and act locally. It is an opportunity for citizens
during Labor and Delivery
is three times as likely to have a low birth-
in both urban and rural communities to learn
in the United States
weight baby.
from our brothers and sisters around the world
and gain a better understanding of the challenges
One third of women in the United States
we all face. We are not an island. Rather, we are
d Delivery
smoke, including 20% of pregnant women.
inextricably linked. And it doesn't matter if it's a
on(s) and/or
mother and child in Senegal or a mother and
elivery
About one in five women has serious com-
child in Seattle-what we all want is a healthy
plications before labor begins.
outcome.
U.S. infant mortality rates exceed those of
Who can participate?
most other industrialized nations.
Everyone.
Maternal and infant morbidity and mortality
rates differ sociodemographically, ethnically and
How can I get more information?
WHO estimates that about 585,000 women
regionally. For example:
647 P03
worldwide die per year as a result of compli-
Get your free resource booklet by writing or
cations during pregnancy and childbirth. While
African American women are four times as likely
sending electronic mail to the American
in the United States the risk of a woman dying
to die from pregnancy-related causes as Caucasian
Association for World Health. You also can view
from pregnancy has decreased dramatically
women, and mortality rates of African American
or download the booklet from AAWH's Web
over the past 50 years and currently is similar
babies are twice those of Caucasian babies.
site. The booklet will provide you with direction
to many other developed countries, experts
on how to get involved as well as information
estimate that many deaths are still preventable.
Lack of prenatal care poses a major challenge
specific to Safe Motherhood, including repro-
Leading a healthy lifestyle, planning pregnancies,
for the Hispanic-about 30% of pregnant
MAR 25 '98 16:23
ducible Fact Sheets. It will be available early in
and getting good prenatal, delivery and postna-
Hispanic women do not receive early prena-
1998.
tal care all contribute to healthy outcomes.
tal care.
212-941-5563 FAMILY CARE INTL.
647 P04
MAR 25 '98 16:23
Release
PRO
Population Reference Bureau
For Release:
Thursday, March 5, 1998
1875 Connecticut Ave., NW, Suite 520
Washington, DC 20009-5728
Contact:
Phone: (202) 483-1100
Alene H. Gelbard, 202/483-1100
Fax: (202) 328-3937
Lina Parikh, 202/483-1100
[email protected]
http://www.prb.org/prb/
The World's Women: Making Gains but Still Widely Disadvantaged
To commemorate International Women's Day (March 8), the Population Reference Bureau (PRB) has just
released 1998 Women of Our World, a wall chart detailing the latest available data on the quality of women's lives in 150
countries.
PRB's 1998 Women of Our World highlights important gains women have made in recent years: life expectancy
has increased 19 years since the 1950s; women's participation in the labor force is up 21 percent since the 1960s; literacy
rates have improved 10 percent since the 1970s; and girls' enrollment in secondary school has risen 18 percent since the
1980s.
Despite these gains, data for 150 countries from PRB's new wall chart show that women today still experience
major disadvantages in health, education, work, and politics.
Challenges to Health
Nearly 600,000 women die every year from causes related to pregnancy, childbirth, and abortion. The ratio of
maternal deaths to live births varies enormously throughout the world-from fewer than 10 maternal deaths per
100,000 live births in many European countries and in North America, to more than 1,400 deaths per 100,000 live
births in several countries in sub-Saharan Africa. The majority of maternal deaths (95 percent) occur in Africa and
Asia (see figure 4 on wall chart).
More than 30 percent of births worldwide are not attended by skilled personnel, increasing the risk that mothers
and their babies may die during childbirth. Tremendous regional variation exists in the percentage of births attended
by skilled personnel, from only 33 percent in Eastern Africa to 99 percent in the more developed world (Australia,
Japan, New Zealand, Europe, and North America).
Worldwide, 56 percent of married women practice family planning. The percentage of married women practicing
family planning varies greatly by region, from 13 percent of married women in Western Africa to 81 percent of
married women in East Asia.
Demographic Differences
The average number of children that women bear varies significantly around the world, from less than two
children per woman in Europe and North America to more than six children per woman in Western, Middle, and
Eastern Africa. Data also show that in regions where family planning use is higher, women tend to have fewer
children (see figure 3 on wall chart).
Educational Gaps
Worldwide, fewer women are literate than men (64 percent of women compared with 80 percent of men).
The literacy gaps are greatest in less developed regions, such as Western Africa and South-Central Asia, where
overall literacy levels are low (see figure 1 on wall chart).
(over)
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647 P05 MAR 25 '98 16:24
Worldwide, girls are less likely to be in secondary school than boys (90 girls for every 100 boys enrolled).
These figures mask significant regional differences. In Southern Africa, and in Latin America and the Caribbean,
more girls than boys are enrolled in secondary school: 119 and 114 girls, respectively, for every 100 boys. In Middle
Africa, however, only 61 girls are enrolled in secondary school for every 100 boys.
Work Disparities
Women are less likely to work in the formal labor force than men (54 percent compared with 82 percent of men).
The percentage of adult women in the formal labor force varies widely, from 32 percent of all adult women in
Northern Africa to 71 percent in East Asia and Eastern Africa.
Political Hurdles
Worldwide, women make up a disproportionately small percentage of political decision-makers (12 percent of
national parliaments and 7 percent of ministerial and subministerial-level positions). Regional estimates show a
striking contrast in women's participation in the political process. Women make up 19 percent of national parliaments
in Northern Europe, Western Europe, and Southern Africa, but they make up only 3 percent of national parliaments in
Northern Africa. These regional disparities are even greater at the ministerial level, where women hold 32 percent of
ministerial and sub-ministerial positions in North America but less than 5 percent of these positions in Northern and
Middle Africa, Western Asia, and Eastern Europe.
In addition, PRB's 1998 Women of Our World discusses several issues that also have important implications for policy-
makers, including:
Economic Inequities: Data show that women in nonagricultural jobs are paid less than men. Women's wages as
a percent of men's wages range from 60 percent in South Korea to 91 percent in the Philippines. Only in Australia do
women make about the same as men (see figure 2 on wall chart).
AIDS: In 1997, almost 6,000 women around the world became infected with HIV every day. Globally, women
account for 41 percent of adults who are living with HIV/AIDS (see table 1 on wall chart). The proportion of
HIV-infected adults who are women varies by region. In sub-Saharan Africa, where 19.8 million adults are infected
with HIV (over two-thirds of the world total), women account for one-half of all adults infected with HIV. In most
other regions, women account for one-fifth to one-third of HIV-infected adults. Since the beginning of the AIDS
epidemic, 11.7 million people have died of AIDS, 4 million of whom were women.
Domestic Violence: Women in both less developed and more developed countries are reporting this often hidden
violence in significant numbers (see table 2 on wall chart).
International Women's Day
On March 8, 1857, women in New York City's garment and textile industries protested against low wages, long hours, and inhumane
working conditions. In 1909, the United States began observing National Women's Day. and in 1910 the Women's Socialist
International designated an International Women's Day to mark the garment workers' strike. In 1975, to commemorate the struggle for
women's equality. the United Nations began observing March 8 as International Women's Day.
Copies of 1998 Women of Our World may be purchased for $5 (price includes postage) from PRB by calling 1-800-877-9881;
email: [email protected]. (Will be available in French and Spanish also.) Journalists may receive a free copy upon request.
The Population Reference Bureau is the leader in providing timely and objective information on U.S. and international population
trends and their implications. For more information on membership and publications, please contact PRB.
212-941-5563 FAMILY CARE INTL.
647 P06
MAR 25 '98 16:25
O
FOR MORE INFORMATION
CONTACT: Benna Holden
(202) 973-0369
Safe
"Year of Safe Motherhood"
Motherhood
FACTS AT A GLANCE
Every minute of every day, somewhere in the world, a woman dies from complications related
to pregnancy or childbirth (defined as a maternal death).
Inter-Agency Group
for Safe Motherhood
Approximately 50 million women a year (equivalent to the total population of the countries of
UNFPA
Spain and Portugal) suffer maternal health complications.
UNICEF
WHO
In developing countries, pregnancy and childbirth are the leading causes of death, disease and
WORLD BANK
disability among women of reproductive age:
IPPF
POPULATION COUNCIL
Leading Causes of the Burden of Disease in Worren Aged 1544 In the
Developing World 1990
Respiratory infection
26%
Anemia
25%
Self Inflicted injuries
32%
Depressive disorders
5.8%
HIV
6.6%
Tuberculosis
7.0%
STD
8.9%
Maternal causes
18,0%
0%
2%
@%
6%
8%
10%
12%
14%
16%
18%
20%
Source: World Development Report 1993: Investing in Health. World Bank, Washington, DC, 1993
Worldwide, there are 430 maternal deaths for every 100,000 live births. In developing
countries, the figure is 480 maternal deaths for every 100,000 live births; in developed
countries there are 27 maternal deaths for every 100,000 live births.
A woman's risk of dying from pregnancy and childbirth varies widely by region:
Chairing Agency:
Region
Risk of Dying
IPPF
Africa
1 in 16
Asia
1 in 65
Regent's College, Regent's Park
Latin American & Caribbean
1 in 130
London NW1 4NS, UK
Northern Europe
1 in 4,000
Telephone: 44 171 487 7864
North America
1 in 3,700
Fax: 44 171 487 7865
All developing countries
1 in 48
email: [email protected]
All developed countries
1 in 1,800
Secretariat:
Family Care International
Country-level differences are even more dramatic: for example, in Ethiopia, 1 out of every 9
588 Broadway, Suite 503
women die from pregnancy-related complications, as compared to 1 in 8,700 in Switzerland.
New York, NY 10012 USA
Telephone: 212 941 5300
Fax: 212 941 5563
email: [email protected]
212-941-5563 FAMILY CARE INTL.
647 P07
MAR 25 '98 16:25
There are five main causes of maternal death worldwide:
Causes of Maternal Death
severe bleeding
25%
Infection 15%
Indirect causes
20%
other
eclampsis 12%
direct causes 8%
obstructed labour
unsafe abortion
8%
13%
Source: Maternal Health Around the World, WHO, 1997
Deliverles by Relatives or Alone, Selected Countries
Each year, 60 million deliveries take place in
which the woman is cared for only by a family
Delivery by
Delivery alone
member, an untrained traditional birth
relative/other (%)
(%)
attendant -- or no one at all.
Malawi
41
7
Uganda
35
12
Niger
24
17
Nepal
56
11
Pakistan
52
2
Source: Demographic and Health Surveys, selected countries, various years.
Skilled Attendance at Delivery and Maternal
Mortality Ratios, selected countries
98%
100%
94%
1000
1000
Countries where skilled attendance at delivery
77%
850
800
is low tend to have higher rates of maternal
75%
Skilled Attendance M
600
250
Maternal Mortality Ratio
death and disability. In 1996, skilled birth
650
Delivery
46%
attendants were present at only 53% of births
50%
in the developing world. In developed
31%
400
countries, skilled attendance is nearly
25%
universal.
200
140
5%
90
0%
0
Trinidad
&
Sri
Lanka
Botswane
Bolivia
Nigoria
Bangladesh
Tobago
Skilled Attendance at Delivery
Maternal Mortality Ratio
Source: "Revised 1990 Estimates of Maternal Mortality", WHO, 1996 and "Coverage of Maternal Care", WHO, 1997.
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647 P08
MAR 25 '98 16:26
Child Deaths When a Parent Dies, per 1,000
200
Motherless children are likely to get
150
less health care and education as they
grow up. A study in Bangladesh
100
found that when a mother dies, her
50
children - especially daughters - are
much more likely to die than children
0
whose parents are both alive.
no parent dies
father dies
mother dies
sons
daughters
Source: Mother Baby Package: Implementing Safe Motherhood in countries, WHO, 1994
Most maternal deaths, millions of cases of disease and disability, and the deaths of at least 1.5 million infants
each year could be prevented through:
basic maternal care for all pregnancies, including a skilled attendant (doctor or midwife) at birth;
prevention and treatment of complications during pregnancy, delivery and after birth; and
postpartum family planning and basic neonatal care.
These health care services would cost approximately $3 per person per year in most developing countries.
###
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MAR 25 '98 16:26
O
The "Year of Safe Motherhood"
S
Safe Motherhood is a global effort to increase maternal safety and
reduce the number of deaths and illnesses associated with
pregnancy and childbirth
Women need not die while giving life to future generations.
Every minute of every day, somewhere in the world and most often in a developing nation, a woman
dies from complications related to pregnancy or childbirth. Her death is more than a personal
tragedy, although that alone would merit our most serious concern. In addition, her death represents
an enormous cost to her nation, her community and her family. Any social and economic investment
that has been made in her life is lost. Her family loses her love, her nurturing and her productivity
inside and outside the home. Half of all infant deaths can be attributed to poor maternal health.
Moreover, the child that survives a mother's death is up to ten times more likely to die within two
years than a child with two living parents.
The greatest tragedy is that these approximately 600,000 maternal deaths and over 50 million cases
of morbidity that occur each year are largely preventable. A decade of research has proven that
surprisingly small and affordable measures can significantly reduce the health risks that women face
when they become pregnant.
In 1987 a coalition of the world's leaders in maternal and child health, the United Nations Population
Fund (UNFPA), the United Nations Children's Fund (UNICEF), the World Health Organization
(WHO), the World Bank, the International Planned Parenthood Federation (IPPF) and the Population
Council, joined forces and developed an Inter-Agency Task Force on Safe Motherhood to assess this
problem and recommend solutions.
Now it is time to act upon what has been learned over the past ten years of research and model
projects, before one more woman loses her life needlessly.
To achieve this goal, World Health Day, 7 April 1998 will kick-off a year-long series of activities to
promote Safe Motherhood.
On that day a call to action will be issued to governments, business leaders, policy makers, and
citizens of every country of the world. The call to action consists of four simple messages:
1. International aid agencies are urged to provide overseas assistance to programs that promote
maternal care as an essential component of reproductive health services.
2. Governments of developing countries are urged to reduce maternal mortality and morbidity by
developing and implementing health, nutrition and education programs that promote the health
of pregnant women and their infants.
3. Corporations around the world are urged to encourage governments and private organizations in
the countries where they do business to provide funds and develop programs that foster safe
motherhood, and to support safe motherhood among their employees and customers.
4. Women, men and families everywhere are urged to demand and seek quality prenatal and
obstetric care to ensure that no woman dies or suffers long-term complications from childbirth.
MAR 25 '98 16:27
Safe Motherhood
647 P10
Helping to make women's health
and rights a reality
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MAR 25 '98 16:27
What is the greatest threat to a woman's life
and health in developing countries?
647 P11
Every minute:
380 women become pregnant
190
women face an unplanned or unwanted pregnancy
110
women experience a pregnancy-related complication
40
women have an unsafe abortion
212-941-5563 FAMILY CARE INTL.
1 woman dies
Pregnancy and childbirth.
Why "Safe Motherhood"?
Essential Safe Motherhood Services
647 P12 MAR 25 '98 16:27
Governments and health advocates agree: sexual and reproductive health
Safe motherhood services should be readily available through a network
is essential for national development and personal well-being. And Safe
of linked community health care providers, clinics and hospitals. The
Motherhood is a key component of efforts to improve women's reproduc-
integrated services that policy-makers from around the world have
tive health and rights. Pregnancy and childbirth are the leading causes of
pledged to provide include:
disability and death among women between the ages of 15 and 49, making
Safe Motherhood programs essential for women's health and survival.
Community education on safe motherhood;
More broadly, commitment to Safe Motherhood can galvanize action on
Prenatal care and counseling, including the promotion of
a range of health problems that affect women and their families, including
maternal nutrition;
reproductive tract infections, infertility, HIV/AIDS and other sexually
Skilled assistance during childbirth;
transmitted diseases. It can also encourage attention to social issues, like
Care for obstetric complications, including emergencies,
lack of education, discrimination and violence against women, which can
Postpartum care;
lead to, or worsen, women's poor reproductive health.
Management of abortion complications, postabortion care and,
Death from pregnancy or childbirth is a social injustice that can and must
where abortion is. not against the law, safe services for the
be addressed through political, legal and health systems in every country.
termination of pregnancy;
More than 99 percent of these deaths now take place in the developing
Family planning counseling, information and services;
world. Safe motherhood interventions, which are designed to reduce
Reproductive health education and services for adolescents.
maternal death and disability, are highly cost-effective: basic maternal and
newborn care costs an average of US$3 per person in developing
countries. The total cost of saving the lives of a mother or infant through
Lessons Learned
antenatal, delivery and postnatal care is only $230, while the benefit to
countries, communities and families cannot be measured. Over one-half of
Empower women, ensure their choices: Gender inequalities and
all infant deaths could be prevented through these interventions.
discrimination limit women's choices and contribute directly to their ill-
health and death. Legal reform and community mobilization can help
212-941-5563 FAMILY CARE INTL.
The Safe Motherhood Initiative
women safeguard their reproductive health by enabling them to understand
and articulate their health needs, and to seek services with confidence and
The global Safe Motherhood Initiative was launched in 1987 to improve
without delay.
maternal health and cut the number of maternal deaths in half by the year
2000. It is led by a unique alliance of co-sponsoring agencies who work
together to raise awareness, set priorities, stimulate research, mobilize
Every pregnancy faces risks: Every pregnant woman - even if she is
resources, provide technical assistance and share information. Their
well-nourished and well-educated - can develop sudden, life-threatening
cooperation and commitment have helped governments and non-govern-
complications that require high quality obstetric care. Attempts to predict
mental partners from more than 100 countries take action to make
these problems before they occur have not been successful, since most
motherhood safer. During the Initiative's first decade, these safe
complications are unexpected and the majority of women with poor
motherhood partners developed model programs, tested new technologies
pregnancy outcomes do not fall into any high-risk categories. Therefore,
and conducted research in a wide range of countries and settings. The
maternal health programs must aim to ensure that all women have access
essential services they have identified, and the most important lessons they
to essential services.
have learned, are summarized here.
Each of the co-sponsors of the Safe Motherhood Initiative (see back
panel) implements these activities according to its institutional mandate.
MAR 25 '98 16:28
Ensure skilled attendance during childbirth: The single most effective
Measure progress: Governments around the world have pledged to
way to reduce maternal death is to ensure that a health professional with
reduce maternal mortality by 50% by the year 2000. However, maternal
the skills to conduct a safe, normal delivery and manage complications is
mortality is difficult to measure, due to problems with identification,
present during childbirth. Unfortunately, there is a chronic shortage of
classification and reporting. Therefore, safe motherhood partners have
these professionals in poor and rural communities in the developing world.
developed alternative means for measuring the impact and effectiveness
Research has shown that even trained traditional birth attendants (TBAs)
of programs; for example, by recording the proportion of births attended
have not significantly reduced a woman's risk of dying in childbirth,
by a skilled health provider. These indicators can identify weaknesses and
largely because they are unable to treat pregnancy complications. As an
suggest programmatic priorities so that maternal deaths can be better
647 P13
interim strategy for settings where TBAs attend a significant proportion of
prevented in the future.
deliveries, program planners may want to provide TBAs with adequate
training and support to help them refer complicated cases effectively. In
all settings, however, skilled attendance at delivery should continue to be
A Call to Action
the long-term goal.
Safe motherhood partnerships have been responsible for important
Improve access to high quality maternal health services: A large
international and country-level progress over the last ten years. Collabora-
tion has enabled individual organizations to share their diverse strengths,
number of women in developing countries do not have access to maternal
and to achieve more than they could have alone. During this same decade,
health services. Many of them cannot get to, or afford, high-quality care.
however, six million women have died needlessly in pregnancy or
Cultural customs and beliefs can also prevent women from understanding
childbirth. Your support - and your partnership - can help safe mother-
the importance of health services, and from seeking them. In addition to
hood partners around the world apply the lessons they have learned to save
legal reform and efforts to build support within communities, health
the lives of millions of women before the year 2000. Each minute, each
systems must work to address a range of clinical, interpersonal and
day, in every country.
logistical problems that affect the quality, sensitivity and accessibility of
the services they provide.
Please join us.
212-941-5563 FAMILY CARE INTL.
Address unwanted pregnancy and unsafe abortion: Unsafe abortion
is the most neglected - and most easily preventable - cause of maternal
death. These deaths can be significantly reduced by ensuring that safe
motherhood programs include client-centered family planning services to
prevent unwanted pregnancy, contraceptive counseling for women who
have had an induced abortion, the use of appropriate technologies for
women who experience abortion complications, and, where not against the
law, safe services for pregnancy termination'.
Each of the co-sponsors of the Safe Motherhood Initiative (see back
panel) implements these activities according to its institutional mandate.
Printed on recycled paper
With the compliments of
I
NTERNATIONAL
Programs
Population Reference Bureau, Inc.
1875 Connecticut Ave., N.W., Suite 520
Washington, D.C. 20009-5728
U.S.A.
Phone: (202) 483-1100
Fax: (202) 328-3937
MEASURE Communication
MEASURE Communication
ALL
MEASURE
Rhonda Smith, MPH
MEASURE
Rhonda Smith, MPH
Senior Policy Analyst
Analyste de politiques
Communication Specialist
Spécialiste en communication
Population Reference Bureau
Population Reference Bureau
1875 Connecticut Ave., NW Suite 520
1875 Connecticut Ave., NW
Suite 520
Washington, DC 20009-5728
Washington, DC 20009
Etats-Unis
USA
(202) 483-1100 Fax (202) 328-3937
(202) 483-1100
Fax (202) 328-3937
C. élec. : [email protected]
E-mail: [email protected]
PHOTOCOPY
PRESERVATION
MEASURE Communication
MEASURE Communication
MEASURE
Rhonda Smith, MPH
MEASURE
Rhonda Smith, MPH
Analyste de politiques
Senior Policy Analyst
Spécialiste en communication
Communication Specialist
Population Reference Bureau
Population Reference Bureau
1875 Connecticut Ave., NW
Suite 520
1875 Connecticut Ave., NW N Suite 520
Washington, DC 20009
Etats-Unis
Washington, DC 20009-5728
USA
(202) 483-1100
Fax (202) 328-3937
(202) 483-1100 Fax (202) 328-3937
C. élec. : [email protected]
E-mail: [email protected]
On behalf of the Inter-Agency Group for Safe Motherhood
James D. Wolfensohn, President of the World Bank
cordially invites you to attend a special event in honor of World Health Day
SAFE MOTHERHOOD: PROGRESS AND CHALLENGES
on Tuesday, April 7, 1998
from nine thirty in the morning to one o'clock in the afternoon
at the Lewis Preston Auditorium
The World Bank, 1818 H Street, N.W. Washington, DC
RSVP BY MARCH 20, 1998
DUE TO SECURITY REQUIREMENTS,
MAMTA KAUSHAL, THE WORLD BANK
PARTICIPANTS MUST BE
TEL: 202 458-8344; FAX: 202 522-2653
SEATED BY 9:00AM
OR
ANNC Tinker - DirectoR of Safe Motherhood
Initiative
[World Bank. (502) 473-3683
Safe Motherhood: Progress and Challenges
a symposium with:
His Excellency Yoweri Museveni, President of Uganda (invited)
First Lady Hillary Rodham Clinton, United States of America
The Honorable Kofi Annan, Secretary General of the United Nations, (invited)
James D. Wolfensohn, President of the World Bank
and
Mahmoud Fathalla, Senior Advisor, The Rockefeller Foundation
Nafis Sadik, Executive Director, UNFPA
Carol Bellamy, Executive Director, UNICEF
Sir George Alleyne, Regional Director, PAHO
David de Ferranti, Vice President, Human Development Network, The World Bank
Ingar Brueggemann, Secretary General, IPPF
Margaret Catley-Carlson, President, The Population Council
Richard Feachem, Director of Health, Nutrition & Population, The World Bank
Tuesday, April 7, 1998
9:00 a.m.-1:00 p.m.
Lewis Preston Auditorium
The World Bank, 1818 H Street, N.W. Washington, D.C.
PRS
PRO
How Does
Population
Reference
Family Planning
Bureau
1875 Connecticut
Family planning is a low-cost way to save lives: Family
Avenue, NW,
Save Lives?
planning costs, on average, less than US$2 per capita per year.
Suite 520
Washington
Governments support family planning: Governments world-
DC 20009 U.S.A.
FactS heet
wide are committed to improving the health and survival of
hone:
(202) 483-1100
women and children through family planning. Approximately
E
very year more than 585,000 women die from
Fax:
three-quarters of the costs of family planning are currently
(202) 328-3937
complications of pregnancy and childbirth, and at least
paid for by developing countries.
11 million children under age five die in developing countries.
[email protected]
Family planning can prevent
Demand for family planning will continue to increase:
Page:
http://www.prb.org
many of these deaths by
The United Nations estimates that annual expenditures for
Infant Mortality by Birth Interval
helping couples avoid child-
family planning will have to double by the year 2000, from
September 1997
bearing during times of
140
US$4.8 billion in 1994 to US$10 billion, to meet projected
134
128
high health risk for mothers
120
Less than
Deaths per 1,000 infants under age one
118
demands. Developing countries will need to increase their
two-year
100
interval
and children.
expenditures to US$6.7 billion and donors will need to
80
At least
81
two-year
contribute US$3.3 billion to cover these expected costs in
Saving
60
70
interval'
Children's Lives
40
the year 2000.
Closely spaced births result
20
0
in higher infant and child
mortality: Babies born less
More information about the health benefits of family
than two years after their
SOURCE: Unpublished analysis of Demographic and Health Surveys, 1990-1995
(Calverton; MD: Macro International, 1996).
planning can be found in the booklet, Family
next oldest brother or sister
Planning Saves Lives (January 1997), available
are twice as likely to die in
from the Population Reference Bureau.
the first year as those born after an interval of at least two years.
Spacing births can prevent an average of one in four
infant deaths: By spacing births at least two years apart,
family planning can prevent an average of one in four
infant deaths in developing countries.
Children born to young mothers are more likely to die:
Children born to women younger than age 20 are one and
one-half times more likely to die before their first birthday as
those born to mothers ages 20 to 29.
Saving Women's Lives
76,000 deaths every year, mostly in developing countries.
At least one woman dies every minute from causes related to
Family planning can prevent many of these tragic deaths by
pregnancy and childbirth: In developing countries, a woman's
reducing the number of unintended pregnancies that result
lifetime risk of dying from
in abortions.
Women's Risk of Death from Pregnancy
pregnancy and childbirth-
Family planning is safe and effective: The risk of dying from
and Childbirth
related causes is 38 times
Lifetime risk
use of modern methods of family planning is far less than the
Region
of death
higher than the risk
risk of death associated with pregnancy and childbirth.
World
1 in 60
for a woman in more
More Developed
1 in 1,800
A Cost-Effective Way
developed regions.
to Save Lives
Developing
1 in 48
Family planning can
More than half of all couples in the developing world are using
Africa
1 in 16
1 in 65
prevent at least 25 percent
family planning to achieve their desired family size, and the
Asia
Europe
1 in 1,400
of all maternal deaths:
demand for family plan-
Latin America/Caribbean
1 in 130
Family planning can save
ning continues to grow.
Demand for Family Planning
North America
1 in 3,700
women's lives by allowing
There is a large
(Demand = Current Use + Unmet Need)
Oceania
1 in 26
90
women to delay motherhood;
unmet need for family
80
D
SOURCE: WHO and UNICEF, Revised 1990 Estimates of Maternal Mortality,
prevent unintended pregnan-
planning: Surveys find that
70
A New Approach by WHO and UNICEF (Geneva: World Health
72
Unmet need
36
Organization, April 1996):3, 6.
60
16
DD
(Women who
cies and unsafe abortions;
want to space
an estimated 150 million
50
55
or limit births
48
but are not
protect themselves from
40
women in developing
28
currently using
30
family planning)
33
sexually transmitted diseases, including HIV/AIDS; and stop
countries are in need of
Percent of married women ages 15-49
21
20
Current use
childbearing when they have reached their desired family size.
10
family planning. Meeting
12
6
0
Young women and those with pre-existing health problems face
just the existing demand
Nigeria
ESYPI
Indenesta
Pakistan
Colombia
higher risks: Women ages 15-19 are twice as likely to die from
for family planning could
causes related to pregnancy and childbirth as women in their 20s.
reduce the number of
SOURCE: Demographic and Health Surveys, 1990-1995 (Calverton, MD:
Macro International).
Women who are physically and nutritionally drained, and those
maternal deaths and
suffering from pre-existing illnesses, are also at higher risk of
injuries by as much as
illness and death.
20 percent.
Family planning prevents abortions: An estimated 20 million
unsafe abortions take place each year in places where access to
safe abortion is limited. Unsafe abortions result in at least
APR-01-98 WED 02:17 PM PUBLIC AFFAIRS & COMMUNI FAX NO. 203 226 6709
P. 01
Y
Save the Children.
54 Wilton Rd. Westport CT 06881
FAX
FAX
Date:
4/1/98
To:
Christie Macy
Fax:
202-456-5709
Phone:
202-456-6266
From:
Marianne LeVert
Public Affairs and Communications
Phone:
203-221-4116
Fax:
203-226-6709
Number of pages, including this transmittal sheet: 4
Memo:
Press about The First Lady's trip to Nepal (April 1995).
White House press release: Clean Delivery Kits.
Announcement of First Lady's receipt of Save the Children's Distinguished Service Award
at White House ceremony (for background ).
Should you need additional information, please do not hesitate to call me at 203-221-
4116.
APR-01-98 WED 02:17 PM
PUBLIC AFFAIRS & COMMUNI
FAX NO. 203 226 6709
P. 02
04-04-1995 28:32
00077-1-415996
M.N. INTERNATIONAL
Resend
NW
White Houx Press Release
NAME
THE SAFE HOME DELIVERY KIT
no
Over 700,000 babies are born in Nepal each year. 650,000 are
delivered at home under primitive conditions with most births not
assisted by trained attendants. More than 75,000 die within the
PKS
first year of life, frequently due to tetanus and sepsis caused
by unhygienic delivery practices. As a result, Nepal's maternal
and infant death rates are among the highest in the world.
clean
The
Home Delivery Kit was designed to prevent such deaths.
ors
It. is the product of two years' research conducted by the Save
the Children Alliance/Nepal with support from His Majesty's
Covernment Institute of Medicine and Ministry of Health, funding
assistance from UNFPA and UNICEF, and tochnical assistance from
USAID and PATH/US. In 1994, a private company, Maternal and Child
Health Products Pvt. Ltd. (MCHP) of Kathmandu, was established
with start-up funding and technical assistance from USAID/Nepal
through Save the Children/US. This ground-breaking micro-
enterprise is owned and operated by Ms. Rukumani Charan Shrestha
(Managing Director), ME. Sumitra Bantawa, and Ms. Renuka
Munakarmi, who each have more than fifteen years' experience in
reproductive health care and women's issues, and Ms. Nigma
Tamrakar, an experienced businesswoman.
The simple, affordable and easy-to-use kit was designed
specifically with the traditional birthing practices particular
to Nepal in mind, which included placing the umbilical cord of
the newborn on a coin or betel nut while being cut. Rather than
trying to change traditions, the kit contains a small, clean,
coin-like substitute as well as soap, a new razor blade, clean
umbilical-cord ties, and a plastic sheet to provide a hygienic
birthing surface. The kit's use will significantly reduce two
major causes of maternal and neonatal death, tetanus and sepsis,
by emphasizing the "three cleans" principle promoted by the World
Health Organization: clean hands, clean surface, clean umbilical-
cord care.
Due to the high illiteracy rate among the population all
instructions consist of clear, unmistakable illustrations.
I I can
Since August 1994, Maternal and child Health Products Put. Ltd.
update
(MCHP) has produced and sold over 100,000 Safe Home Delivery Kits
these
in Nepal, primarily through government and voluntary agencies,
and commercial outlets. The First Lady's visit to Kalimati
sold in drugstores, general stores, and through medical
if you
stats
Clinic represents the official launching of the kit which will be
practitioners and community health workers for about Rs. 20 (40
need
cents). Median income in Nepal is USD 210 per year.
them
The Safe Home Delivery Kit is valuable proof that governments,
donor and voluntary agencies, and the private sector can work
together constructively to develop innovative health-care
products that benefit a large segment of the population and have
a high potential for becoming self-sustaining within a short
period of time.
WHITE HOUSE PRESS RELEASE
15/m Y,
APR-01-98 WED 02:18 PM
PUBLIC AFFAIRS & COMMUNI
FAX NO. 203 226 6709
P. 03
Clinton visits the USAID-assisted International Center for Diarrheal Disease Control in Bangladesh, where
gral rehydration therapy was developed.
visit to
While in Kathmandu, Nepal, Clinton
activities encouraging broad-based eco-
our program
toured a small health and family planning
nomic growth, protecting the environment
clinic financed by a partnership of USAID,
and building democracy.
IN NepAL
Save the Children Foundation and the
"If my visit to other countries in the
government of Nepal. Here the first lady
region highlighted the development
APRIL 1995
was given a "Safe Home Delivery Kit" for
challenges and opportunities facing the
expectant mothers. The primitive kit,
region, my visit to Sri Lanka underlined the
consisting of soap, twine, wax, a plastic
fact that those challenges can be met and
C so "three years
sheet and razor blade, denotes the extent to
just how important health, education and the
ago This month,
which development still remains a challenge
inclusion of women can be in achieving
economic progress anywhere in the world,"
Clinton noted.
In an article the first lady wrote that ran
"One lesson the experience of
in The Washington Post on May 14, she
the last several decades teaches
praised USAID activities in South Asia:
"These projects are proof that American aid
us is that where women prosper,
- both financial and technical - has
countries prosper."
provided the tools of opportunity to people
and nations who have shown a courageous
commitment to democracy and a market
to Nepal, one of the poorest countries in the
economy. Today, that American aid
world.
remains critical. Having watched in the last
In Bangladesh, Clinton visited the
10 years as democracy has flourished and
USAID-assisted International Center for
markets have opened around the globe, we
Diarrheal Disease Control, which has been key
cannot runn our backs on nations struggling
in helping save people suffering from
to uphold our ideals."
cholera, malnutrition and diarrhea. It was at
this center that oral rehydration therapy was
initiated and then launched worldwide.
Clinton's last stop was Sri Lanka, the
most socially progressive of the countries
visited. Here USAID is committed to
lot
APR-01-98 WED 02:18 PM PUBLIC AFFAIRS & COMMUNI
FAX NO. 203 226 6709
P. 04
VMS
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DATE
Transcript
September 18, 1995
TIME
7:00-7:30 PM (CT)
NETWORK
CNN
PROGRAM
Headline News
Lynne Russell, anchor:
First Lady Hillary Clinton received a Distinguished
Service Award from Save the Children at the White House
today. The international relief organization commended her
efforts to give the less fortunate--especially women and
children--a chance, a voice, and a future. She plans to
publish a book on children's issues this fall.
# # #
FYI: SAVE the Children
awarded the first Lady
the Destyvished service AWARD
five months after trip
to Nepal.
For a videocassette(TV) or audio cassette(radio) of this news segment contact your nearest VMS office.
NOTICE: (c) Cable News Network, hr. 1996 AS Aights Received
Material supplied by Video Manitaring Services of America, Inc. may only be used for internal revinw, analysis or research. Any publication, rebrondcast or oublic
Save the Children.
To:
Christie Macy
Office of the First Lady
Fr:
Marianne LeVert
Save the Children
Re:
Clean Birthing Kit
April 2, 1998
Enclosed please find a sample Clean Birthing Kit and an updated fact sheet about the kit
and its use.
The contents of the kit include:
a fold-out pictorial guide to the birthing process using Nepalese script and women in
traditional clothes
a clean plastic sheet for a sanitary surface for the mother
a bar of soap with which the birthing attendant should wash her hands
a clean razor blade to cut the umbilical cord
a clean plastic disk on which to cut the cord
a clean string to tie off the cord
Maname lovert
Clean Birthing Kit
Contents:
a pictorial guide to the birthing process using Nepalese script
and women in traditional clothes
a clean plastic sheet for a sanitary surface for the mother during
birth
a bar of soap with which the birthing attendant should wash her
hands
a clean razor blade to cut the umbilical cord
a clean plastic disk on which to cut the cord
a clean string to tie off the cord
UPDATED KITIN70
Clean Birthing Kit
Nepal is one of the most mountainous and geographically diverse countries in the
developing world. Remote villages are perched on the highest mountain ranges,
communities are often isolated by the four month monsoon, and there are great
distances between poorly equipped government health posts. All of this makes the
delivery of health care difficult under the best of circumstances.
In Nepal, over 700,000 babies are born each year. More than 75,000 Nepali children
will die within the first year of life, and approximately 539 mothers will die due to
pregnancy or delivery each year per 100,000 live births*. Some of these deaths can be
attributed to tetanus and other infections arising from delivery under unhygienic
conditions. The vast majority of deliveries still take place at home, usually under
unsanitary conditions. Births often take place on a floor that has been coated with a
mud-dung preparation. Birth attendants are frequently relatives or neighbors who have
little experience and no training in clean birth practices. Often, these untrained birth
attendants do not wash their hands before assisting with birth, and do not take other
hygienic precautions before caring for the cord. For example, the cord is usually cut
with a dirty sickle, knife or blade against the surface of an unclean coin or locally
available nut (betal nut). In addition, septic substances, typically mustard oil and/or
prepared powders, are often applied to the cord.
The World Health Organization (WHO) has firmly supported the principle of the three
cleans at delivery: clean hands, clean surface, and clean cord-cutting implement, in
conjunction with their Expanded Program on Immunization goal to eliminate neonatal
tetanus. Based on the importance of the "3 cleans," and our desire to improve birthing
practices in Nepal, Save the Children US, with its Alliance partners Redd Barna of
Norway and Save/UK, initiated a research project in 1993, with support from UNICEF,
UNFPA, and USAID, to examine the acceptability of the Clean Birthing Kit. In 1994, the
Clean Birthing Kit, or in the local Nepali Language, "Sutkeri Samagri" ("Delivery Items"),
went in to production. A unique, woman-owned, Nepali-based microenterprise, Maternal
and Child Health Products Pvt, Ltd (MCHP), has been marketing and selling the product
ever since. To date, over 100,000 kits have been sold, for approximately 27 cents a
piece.
The contents of the kit, a small cardboard box only about 3.5 inches long by 2 inches
wide, include fold-out pictorial instructions (using Nepali script and pictures of women
dressed in traditional clothes) of the actual birthing process; a clean plastic sheet to
provide a sanitary surface during birth; a bar of soap with which the birthing helper
washes her hands; a clean razor blade to cut the cord; a clean plastic disk on which to
cut the umbilical cord; and a clean string to tie off the umbilical cord.
The Clean Birthing Kit, a simple, cost-effective product, has broadened awareness of
the importance of "a clean start" throughout many villages of Nepal.
*Nepal Family Health Survey, 1996, Ministry of Healthfile: C/Kim/Birthkit
A
Regarding the finding of epidemiologic studies of workers exposed to health and safety
hazards:
"Statistics are people with the tears wiped off."
Irving Selikoff, the pioneer who first
linked asbestos exposure to the
premature deaths of New Jersey
insulation workers
Insult, Injury, Asylum: Genital Mutilation Was Only the Beginning
vital context for her story. Suc- Rcut SO she clean for
three, times flocked in maxi
mother swexplanation of the
DO THEY HEAR YOU
cinclly depicted, that of her life him. In the most suspenseful chap
mum security. wards with crimi-
episode after it was over
WHEN YOU CRY
sheds light on ethnic groups, Islam sister Avisha executes
nals, including a cellmate who was
The most impressive human ac
By Fauziya Kassindja and Layli Miller
and custom, which weigh far more ing,
convicted murderer, housed with
complishment in? Do They Hear
Bashir
than government or law and the
Afteria brief Germany
smokers despite asthma, repeated
You When You Cry" is Kassindja
Delacorte. 518 pp.
supreme importance of family
Kassindja arrived in the United
y denied access to doctors, misdi
strength and iousness
delightful description of her sister
States: where: she has relatives
agnosed and denied medical treat
hough she was disappointed
Reviewed BY LOBI ROBINSON
Ayisha's four day wedding illumi
assuming that asylum would be
ment peptict ulcer disease.
when her mother apologized to her
nates those values. particularly
easy to secure. My, teachers
Profound haos and appalling in
contributing editor of Emerge
uncle (for the sake of peace in the
magazine who working on book
well.
school had:said it was great
justices plague detained
family) for helping with the es
about sexual
Kassindia parents followed
country They said people believed
grants, who are portionately,
in justice in America, she recalled
people of color.
cape, Kassindja declares peace her
most tribal traditions but [confi-
But within her first hours on U.S.
Aimajor disappointment of the
giself. Tm grateful to the American
round the world rituals
dently bucked those they, founds
soil Kassindia was p-searched
book is the hasty. retelling of the
people and government for every
marking girls passage into
unacceptable Her father married
adulthood Jewish bat
twice, left naked in a putrid, freez-
appeal hearing, arguably the
thing they done for me, taking
Y JOHN EARLE
only one woman, from outside his
ing holding room, forced to shower
book most anticipated scene. The
me in; giving me shelter, giving me
Fauziya Kassindja escaped the fate
mitzvahs, Latin American quince
tribe, provoking vocal disapproval
in cold water while guards
authors should have more thor
sate place to live
THE
of millions of girls worldwide.
aneras are joyous" occasions
by his siblings: He also defied
stared, and berated by an immigra
oughly explained: the legal-argu
Then there is amputation without
custom by rejecting female cutting
tion: official: SI don't know whyst
ments made by both sides of the
anesthesia. What a way to grow up
So deep was his conviction that he
these people can't stay in their own
case, as they summarized well the
overnight
Main
said he would*never, forgive his
countries. When she asked where
legal and political actions leading
An estimated 100 million girls
brother for secretly arranging the
she could put her souled samitary
up to that moment.
and women have had their genitals
cutting of their niece.
napkin, a, guard barked,9 Why
Ultimately, the dramatic legal
sliced or scraped off in a procedure
When Kassindja's father died,
don't you eat it It got worse 433
and media strategies of lawyers,
known as female circumcision, cut
that same uncle became her legal
During 16 months of confine
law students; human rights advo-
ting or genital mutilation. A tradi
guardian; as mandated by tradi-
ment in one detention center and
cates and reporters won Kassind-
tion practiced in more than 25
tion. Soon she was pulled out of
three prisons; she was tear gassed
ja freedom; setting legal prece
African countries and a few West
school and forced to marry a man
and beaten, searched with
dents for future asylum seekers
ern and Southern countries,
with three wives who wanted her
other women, placed in segrega
You God's chosen one, was
it can cause a host of health prob
250
lems and even death To be pro
tected from it by family in a culture
in which women and men fiercely
champion it would be good for
tune. But what if to escape cutting
meant fleeing into the unknown?
N Fauziya Kassindia lived that sce
nario; landing in the United States
at age 17 Her special welcome to
PHOTOCOPY
this country, compliments of: the
Immigration and Naturalization
PR
ERVATION
Service, amounted to more than a
year of umpr risonment and consis
tent human rights abuses: In Do
They Hear You When You Cry,
Kassindja, along with one of her
lawyers, Layli Miller Bashir, re-
counts her at arduous journey. from
Togo to detention as an: illegal
alien, and ultimately to freedom T4
Toldein Kassindja voice, (this
memoir is also) a precious lesson
about cultures, women human
rights policy and perhaps most
important, faith in God, and hu
manity These elements; fluidly
interwoven, create an incredible
narrative about an ordinary teen
age girl. MAIL
* Rarely in Western culture do
well rounded accounts of life
abroad particularly in underdevel-
oped countries; get told. Kassind
ja description of her "easy and
tranquil childhood ma Togo: is
refreshing in itself and also serves
Record Type: Record
To:
Christine N. Macy/WHO/EOP
CC:
Subject: MRS. CLINTON URGES FOCUS ON MATERNAL HEALTH
I should have thought to send this to you yesterday sorry.
Forwarded by Neera Tanden/WHO/EOP on 04/08/98 11:53 AM
TANDEN N @ A1
04/07/98 03:58:00 PM
Record Type: Record
To:
Neera Tanden
CC:
Subject: MRS. CLINTON URGES FOCUS ON MATERNAL HEALTH
Date: 04/07/98 Time: 14:51
MMrs. Clinton urges focus on maternal health
WASHINGTON (AP) In the time it took Hillary Rodham Clinton to
deliver her World Health Day speech, she said, an estimated 15
women died around the globe from pregnancy complications or unsafe
abortions.
No woman should ever die in childbirth," Mrs. Clinton
declared Tuesday, calling for renewed global attention to maternal
health. The vast majority of these deaths and so much of that
suffering could have been avoided."
Nearly 600,000 women and girls, most in developing nations, die
each year while pregnant or in labor due to complications,
including self-induced abortions, according to the World Health
Organization and UNICEF.
Breaking down the statistics, Mrs. Clinton said that every
minute, a women or girl dies, 40 have unsafe abortions, 110
experience a pregnancy-related problem and 190 face an unplanned
pregnancy.
Mrs. Clinton, speaking to several hundred health care
professionals and private and public policymakers at World Bank
headquarters, said countries should develop better family-planning
and education programs for women and children to combat maternal
mortality.
On that point, she criticized conservative members of Congress
who each year try to block U.S. government money for international
family planning, which critics contend lead to abortions.
Without it (family planning) women often turn in desperation
to illegal, unsafe abortion procedures that can account for up to
half or more of all maternal deaths," Mrs. Clinton said.
I would like to stress that point because there are some in
our Congress and in our country who do not understand how providing
family-planning services helps reduce the rate of abortion."
Mrs. Clinton, who last week returned from a 12-day tour of
sub-Saharan Africa with President Clinton, noted that she and her
husband visited projects promoting women and children to underline
U.S. support for human rights and particularly the right to
health."
Supporting Mrs. Clinton at the World Health Day celebration,
Malaysia's first lady, Siti Hasmah Mohd Ali, called for the
elimination of cultural and social taboos" that often prevent
women and girls from making their own reproductive decisions.
Safe motherhood is a basic human right," she said.
Carol Bellamy, executive director of the United Nations
Children's Fund, said her visit last week to Afghanistan, where
women suffer harsh discrimination under Taliban rule, demonstrated
to her that women without equal human rights are in mortal danger.
It is no coincidence that Afghanistan is distinguished
both by severe economic and social restrictions on women and by the
highest maternal mortality rate of any developing country 1,700
deaths per 100,000 live births a truly shocking number," Bellamy
said.
In the United States, by comparison, from 10 to two dozen women
die for every 100,000 live births, according to various federal
surveys.
Bellamy and Mrs. Clinton said simple hygienic handling of mother
and baby can save lives at an estimated cost of $3 per person per
year.
APNP-04-07-98 1450EDT
APR-01-98 WED 01:44 PM PUBLIC AFFAIRS & COMMUNI FAX NO. 203 226 6709
P. 01
Y Save the Children.
54 Wilton Rd. Westport CT 06881
FAX
FAX
Date:
4/1/98
To:
Christie Macy
Fax:
202-456-5709
Phone:
202-456-6266
From:
Marianne LeVert
Public Affairs and Communications
Phone:
203-221-4116
Fax:
203-226-6709
Number of pages, including this transmittal sheet:
Memo:
As you indicated that less material was better than more and short answers more helpful
than long, I am sending you several short pieces:
Press about The First Lady's trip to Nepal (April 1995).
One paragraph descriptions of Clean Delivery Kits and of safe delivery programs.
White House press release: Clean Delivery Kits.
Announcement of First Lady's receipt of Save the Children's Distinguished Service Award
at White House ceremony.
Should you need additional information, please do not hesitate to call me at 203-221-
4116.
when to seek care outside the home, and proper home follow-up
care.
Save the Children's community-level programs link
volunteers, village health action teams, and local ministry of
health systems, among others, We also foster partnerships with
residents respected for their traditional health knowledge--
including both traditional healers and traditional birth attendants.
Common program themes include nutrition education: improved
case management for illness and disease: immunization;
breastfeeding and family planning--including counseling for
HIV/AIDS; safe motherhood initiatives: transport systems for
obstetric emergencies; school health programs, and water and
sanitation improvements.
Such capacity-building and system-strengthening at the
local level means that even when Save the Children's active
programs come to a close, the benefits of improved health
Achean Delivery Kits
knowledge and services serve families and communities through
(short answer)
future generations.
Collaborative multi-level program effort in
In Malawi, one community-based program initiated by
Nepal:
Save the Children involves village funds for improving access to
Clean Delivery Kits
life-saving drugs. Working with Village Health Action Teams in
Save the Children developed "Clean Delivery
communities more than five kilometers away from a government
Kits" in Nepal to address common unhygienic
birthing practices that can cause severe
medical facility, Save the Children helps set up community
maternal and infant health problems, including
fatal infections. To make the kits as useful and
pharmacies stocked with five drugs that are essential for treating
culturally responsive as possible, Save the
Children collaborated with local organizations
the four most common childhood infections--fever/malaria,
on both developing and producing them. In
pneumonia, diarrhea, and eye infections. A volunteer designated
designing and implementing the research for
the kits, we worked with a number of local
by the team learns basic assessment and treatment skills, is
organizations, To produce them, Save the
Children collaborated with a local women-
trained to identify danger signs pointing to the need for hospital
owned firm. And to market the kits, we
partnered with the Ministry of Health in a social
care, and keeps records of clientele, diagnosis, drugs and doses,
marketing program to publicize availability and
and money received.
carry out ongoing distribution.
The informal pharmacies are typically able to provide anti-
malarial treatment for scores of feverish children every month--
many of whom may have lost their lives to the disease. In
10f2
P. 02
FAX NO. 203 226 6709
COMMUNI
8
AFFAIRS
PUBLIC
Wd
St:
REPRODUCTIVE HEALTH PROGRAM PROFILES:
CHOICES FOR A CHANCE
Save the Children's longstanding community-based
Promoting individual
approach to health gives us a strong foundation to promote
and family health, and
participatory reproductive health services shaped by local needs.
helping people avoid the
By developing partnerships and reinforcing networks between
personal burdens associated
local and national groups and government agencies, Save the
with reproductive and sexual
Children's programs strengthen the health services available to
health problems are the goals
families and communities,
of Save the Children's
Our reproductive health programs incorporate efforts in
reproductive health
five main areas: family planning, safe pregnancy and delivery,
initiatives.
Refining
sexually-transmitted diseases--including HIV/AIDS, education--
strategies, maximizing
especially for women and girls, and community-based economic
resources, and learning from
experience is the constant
development.
work of our programs around
Under the umbrella of family planning, Save the Children
the world.
includes fertility awareness, contraceptive information,
education, counseling, and service provision in voluntary
programs designed to address local concerns.
[NEED? ELABORATE?)
Women's Education: The poor record of
many countries in educating their daughters as
Our safe delivery programs teach women and their
diligently as their sons has a generational
impact on women, families, and societies.
families to identify danger signs during pregnancy and
Many studies have clarified the positive,
delivery and develop a birth plan for accessing emergency
profound and lasting changes engendered by
increasing access to education for women and
obstetric care if needed. We also focus on providing
girls. (include fundamental improvements in
women's capacity to care for herself and for
training for traditional birth attendants and village health
those who depend on her,)
promoters, strengthening pre- and post-natal care,
working with safe birth kits, and establishing village-
what safe
based referral services.
delivery programs
do for women's
To help communities reduce the incidence of sexually-
health.
transmitted diseases and improve treatment programs,
Save the Children emphasizes education, communications
and awareness programs--including community drama
presentations; strengthening diagnostic and treatment
2012
P. 03
FAX NO. 203 226 6709
PUBLIC AFFAIRS & COMMUNI
APR-01-98 WED 01:45 PM
Clinton visits the USAID-assisted International Center for Diarrheal Disease Control in Bangladesh, where
'oral rehydration therapy was developed.
visit to
While in Kathmandu, Nepal, Clinton
activities encouraging broad-based eco-
our program
toured a small health and family planning
nomic growth, protecting the environment
clinic financed by a partnership of USAID,
and building democracy.
IN NepAL
Save the Children Foundation and the
"If my visit to other countries in the
government ur Nepal. Here the first lady
region highlighted the development
APRIL 1995
was given a "Safe Home Delivery Kid" for
challenges and opportunities facing the
expectant mothers. The primitive kit,
region, my visit to Sri Lanka underlined the
consisting of soap, twine, war. a plastic
fact that those challenges can be met and
C so "three years
sheet and razor blade, denotes the extent to
just how important health, education and the
a90 This month,
which development still remains a challenge
inclusion of women can be in achieving
economic progress anywhere in the world,"
Clinton noted.
In an article the first lady wrote that ran
"One lesson the experience of
in The Washington Post on May 14, she
the last several decades teaches
praised USAID activities in South Asia:
"These projects are proof that American aid
us is that where women prosper,
both financial and technical - has
countries prosper."
provided the tools of opportunity to people
and nations who have shown a courageous
commitment to democracy and a market
to Nepal, one of the poorest countries in the
economy. Today, that American aid
world.
remains critical. Having watched in the last
In Bangladesh, Clinton visited the
10 years as democracy has flourished and
USAID-assisted International Center for
markets have opened around the globe, we
Diarrheal Disease Control, which has been key
cannot turn our backs on nations struggling
in helping save people suffering from
to uphold our ideals."
cholera, malnutrition and diarrhea. It was at
this center that oral rehydration therapy was
initiated and then launched worldwide.
Clinton's last stop was Sri Lanka, the
most socially progressive of the countries
visited. Here USAID is committed to
/ of
FRONT LINES / 1995
3
P. 05
FAX NO. 203 226 6709
PUBLIC AFFAIRS & COMMUNI
APR-01-98 WED 01:46 PM
Resend
Nru
White Houre Press Release
THE SAFE HOME DELIVERY KIT
no
Over 700,000 babies are born in Nepal each year. 650,000 are
delivered at home under primitive conditions with most births not
assisted by trained attendants. More than 75,000 die within the
PM
first year of life, frequently due to tetanus and sepsis caused
by unhygienic delivery practices. AS a result, Nepal's maternal
and infant death rates are among the highest in the world.
cleun
The
Home Delivery Kit was designed to prevent such deaths.
(
It is the product of two years' research conducted by the save
the Children Alliance/Nepal with support from His Majesty's
Government Institute of Medicine and Ministry of Health, funding
assistance from UNFPA and UNICEF, and technical assistance from
USAID and PATH/US. In 1994, a private company, Maternal and child
Health Products pvt. Ltd. (MCHP) of Kathmandu, was established
with start-up funding and technical assistance from USAID/Nepal
through Save the Children/US. This ground-breaking micro-
enterprise is owned and operated by Ms. Rukumani Charan. Shrestha
(Managing Director), Ms. Sumitra Bantawa, and Ms. Renuka
Munakarmi, who each have more than fifteen years' experience in
reproductive health care and women's issues, and Ms. Nigma
Tamrakar, an experienced businesswoman.
The simple, affordable and easy-to-use kit was designed
specifically with the traditional birthing practices particular
to Nepal in mind, which included placing the umbilical cord of
the newborn on a coin or betal nut while being cut. Rather than
trying to change traditions, the kit contains a small, clean,
coin-like substitute as well as soap, a new razor blade, clean
umbilical-cord ties, and a plastic sheet to provide a hygienic
birthing surface. The kit's use will significantly reduce two
major causes of maternal and neonatal death, tetanus and sepsis,
by emphasizing the "three cleans" principle promoted by the World
Health Organization: clean hands, clean surface, clean umbilical-
cord care.
Due to the high illiteracy rate among the population all
instructions consist of clear, unmistakable illustrations.
I can
Since August 1994, Maternal and child Health Products put. Ltd.
update
(MCHP) has produced and sold over 100,000 Safe Home Delivery Kits
in Nepal, primarily through government and voluntary agencies,
and commercial outlets. The First Lady's visit to Kalimati
theses
Clinic represents the official launching of the kit which will be
ifyou
sold in drugstores, general stores, and through medical
practitioners and community health workers for about Rs. 20 (40
need
cents). Median income in Nepal is USD 210 per year.
them
The Safe Home Delivery Kit is valuable proof that governments,
donor and voluntary agencies, and the private sector can work
together constructively to develop innovative health-care
products that benefit a large segment of the population and have
a high potential for becoming self-sustaining within a short
period of time.
WMITE HOUSE PRESS RELEASE
15/17 Yelf,
P. 04
APR-01-98 WED 01:46 PM PUBLIC AFFAIRS & COMMUNI FAX NO. 203 226 6709
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Transcript
DATE
September 18, 1995
TIME
7:00-7:30 PM (CT)
NETWORK
CNN
PROGRAM
Headline News
Lynne Russell, anchor:
First Lady Hillary Clinton received a Distinguished
Service Award from Save the Children at the White House
today. The international relief organization commended her
efforts to give the less fortunate--especially women and
children-- chance, a voice, and a future. She plans to
publish a book on children's issues this fall.
###
FVI ; SAVE the Children
awarded the first hady
the Destuzuished senice AWARD
five months after trip
to Nepal.
For a videocassette(TV) or audio cassette(radio) of this news segment contact your nearest VMS office.
Material supplied by Video Monitoring Services of America, Inc. may only be used for Internal review, analysis or research Any publication, re-brundeast or public display for protit is fortinition.
NOTICE: (c) Cable News Network, Inc. 1995, All Rights Reserved. Prepared by Vidoo Monitoring Services of America, Inc. which takes sale responsibility for the accuracy of transcription.
90 'd
FAX NO. 203 226 6709
APR-01-98 WED 01:47 PM PUBLIC AFFAIRS & COMMUNI
THE WHITE HOUSE
WASHINGTON
OFFICE OF
SPEECHWRITING
Fax: (202)456-5709
Phone: (202)456-2777
TO:
Sill Sheffield 40 MUMTA
Fax:
522-2653 Phone: 473-3691
FROM:
Comments:
Date:
Number of pages (including cover):
HILLARY RODHAM CLINTON
SAFE MOTHERHOOD: WORLD HEALTH DAY
THE WORLD BANK
APRIL 7, 1998
It is a great honor and pleasure to be here at the World Bank, and to join James
Wolfensohn and all of you as we celebrate World Health Day -- and recommit ourselves to the
global mission of Safe Motherhood. Thank you for giving me this opportunity to speak to you
about a subject so close to my heart -- and of such extraordinary significance to the future of our
world. I'm so pleased to be joined by Dr. Crispus Kiyonga, the minister of Health in Uganda,
where I have just visited -- and Dr. Siti Hasmah Mohd -- the first lady of Malaysia. Deep
appreciation to the members of the Safe Motherhood Inter-Agency Group -- the World Health
Organization (WHO), UNFRA (UN Population Fund), UNICEF, the World Bank, International
Planned Parenthood Federation (IPPF), and the Population Council -- who, with the support of
Family Care International, lead such critical efforts around the globe to promote the health and
well being of women, children and families.
I would also like to acknowledge the extraordinary work of the tens of thousands of foot
soldiers on the front lines -- the doctors, nurses, midwives and public health workers who are
struggling to meet the often overwhelming health needs of women throughout the world -- and
who, against all odds, have saved the lives of so many women and children over the years. We
owe all of them our deepest gratitude.
I want to begin by commending the World Bank for making women's health -- and in
particular -- safe motherhood -- a top priority for international agencies and countries around the
world. Thanks to your work and leadership, and the tireless efforts of all the international
agencies and NGOs here today -- there's a growing understanding of the depth of the challenge
women face around the globe. But perhaps more importantly, there's a growing public
recognition that investments in safe motherhood initiatives have an impact far beyond improving
the status of women and the health of their families. That such investments go hand in hand with
social and economic progress throughout a nation, and the building of democracy around the
globe.
We gather here this morning at a time of great promise and hope. I've just returned from
an historic trip to sub Saharan Africa -- where in just a few years, more than 20 nations have
replaced authoritarian rule with free and fair elections, and where even some of the poorest
countries are beginning the long road toward economic and social recovery. With the worldwide
explosion of technology and information, we are all moving into a global economy, and a truly
new world. And we are in the process -- as a community of nations -- of ending the production
of the weapons of mass destruction, promoting greater human rights, and ensuring a healthier,
cleaner global environment.
Yet in the midst of this time of extraordinary growth and promise -- we still fail to
protect the most precious symbol of the future -- the life and health of our mothers. The figures
are shocking no matter how often they are repeated. Every minute -- 380 women become
pregnant -- 190 women face an unplanned or unwanted pregnancy; 110 women experience a
pregnancy related complication; and 40 women have an unsafe abortion. And every minute,
somewhere on this globe a woman dies from complications of pregnancy and childbirth.
For millions of women around the world, there is no basic primary, reproductive, or
emergency care to keep them alive and healthy. For millions of women around the world, life
threatening complications from childbirth doom not only their own lives -- but the lives of their
children, and the survival of their community. For millions of women around the world, safe
motherhood is a far away dream, a distant reality.
Numbers and charts tell us the terrible dimensions of the health problems facing women
around the world. But not the personal tragedy and pain of losing one's wife, mother, daughter,
sister, or neighbor. As one health care worker admitted: "statistics are people with the tears
wiped off." At the Technical Consultation held in Sri Lanka last year, I'm sure many of you
heard Dr. Mahmoud Fathalla say that "Maternal mortality is not about statistics It's about
women who have names; women who have faces; faces which we have seen in the throws of
agony, distress, and despair." The agony of these deaths is compounded by the simple -- yet
unbearable -- truth that the vast majority of them could have been avoided. They should never
have been allowed to happen.
We are being joined on this day by people in cities and communities around the globe,
who, like us, are raising our voices in unison to say: women need not die while giving life to
future generations. Ten years ago, many of the individuals and agencies and NGOs here today
launched the global Safe Motherhood initiative, and maternal mortality was elevated -- for the
first time -- as an international priority, and goals were set to cut the number of maternal deaths
in half by the year 2000. And while many countries -- including my own -- have not yet met our
goals, we should take pride in the strides we are making.
The signs of progress are all around us. In Bangladesh, Sri Lanka, and Cuba, health
workers trained in midwifery are being assigned to village-based health facilities -- and maternal
mortality has declined. In Ethiopia and Mongolia, women living in remote areas or where
transportation is difficult can now go to maternity waiting homes, and get much needed care. In
Uganda, the "Rescuer's" project ensures pregnant women have radio equipment to call for help.
In country after country, national and local health initiatives are helping to save lives, and ensure
healthier futures, for women and their families.
A few years ago, I toured a small health and family planning clinic in Kathmandu, Nepal,
financed by a partnership among USAID, the Save the Children Foundation, and the government.
And while I was there, I was given a "Safe Home Delivery Kit" -- like the one I have here today
that is given to expectant mothers. Inside is a bar of soap, twine, wax, a plastic sheet and a
razor blade. It's purpose is to reduce the two major causes of maternal and neonatal death
tetanus and sepsis -- by promoting the "three cleans" principle: clean hands; clean surface; clean
umbilical care. These kits are made locally in Nepal by a woman-owned micro-enterprise.
This kit symbolizes for me some of the most important lessons we have absorbed over the
past few years. First we've learned the power of partnership. In community after community,
in nation after nation, governments, voluntary agencies, and local leaders are joining forces --
and resources -- to develop innovate health care strategies and tools that promote safe
motherhood. We now know -- more than ever -- that reducing maternal mortality requires
sustained, long term commitments from the full range of partners in a society. (I know that last
night there was an important meeting of new partners in the corporate sector who are now
joining the World Bank in this safe motherhood campaign -- and agreeing to a set of principles. I
join all of you in applauding their participation.)
But just as importantly, we've learned that the cost of promoting safe motherhood is
often minimal -- this kit costs about 40 cents -- in comparison to the extraordinary rewards in
saved lives, improved maternal and child health, and revitalized communities. So often, it's these
simple, common sense, inexpensive ideas -- like drawing up a roster of vehicles for emergency
transportation of women or setting up a revolving fund for drugs and supplies -- that can have
the greatest impact on reducing maternal mortality.
Think about it. The World Bank estimates that that by spending under $2 a year per
person for health care, almost all of the 600,000 women who die every year during pregnancy or
childbirth would be alive today. And the lives of 1.5 million infants would be saved.
The cruel truth is: as much progress as we've made, as many lessons as we've learned, as
many conferences as we've held, as many partners as we've gained, we have yet to convince
enough of the world's leaders and citizens that maternal mortality is not just a health crisis of
extraordinary proportions. It's a social injustice of the highest magnitude -- and the denial of
the most basic human rights -- including the right to life itself. Martin Luther King Jr. once said
that "of all the forms of inequality, injustice in health is the most shocking, and the most
inhumane." I agree.
There is a painful equity in terms of peril for women during childbirth. Forty percent of
all women -- whether they live on the upper side of New York city or the shanty towns of
Soweto -- have complications. And 15% of all women have life threatening complications.
What happens as a result of those complications -- whether a woman or her child lives or dies --
depends not on the content of her character, as Dr. King would have said, but on the
neighborhood in which that woman lives, the ethnic group to which she belongs, and the social
and economic status of her life. The inequities once again -- are shocking. One woman in
4,000 dies of childbirth in the United States. In Eretria one woman in eleven loses her life.
Here in the U.S., African American women are four times more likely to die from pregnancy
related causes than Caucasian women -- and African American babies are twice as likely to die.
When UNICEF released figures that showed infant mortality was ten times greater in
developing countries than in the developed ones -- there was a collective outcry. Yet maternal
mortality is 150 to 200 times greater in our poorer nations than in our rich ones. And those
deaths are directly related to the high level of poverty and the low status of women in those
countries. That is a moral outrage, and must be recognized as such by every nation in the world.
The inequalities in access to health care are the most obvious -- such as who gets to have
a skilled practitioner by your side during childbirth. Only a third of the women in East Africa
have that luxury, while in most developed countries, it's a universal right.
But these conditions -- and these injustices are not just in our poor, developing
nations. They exist here, in our own backyard -- in our nation's capital, and in inner city
neighborhoods around the United States. Infant mortality here in DC is almost double that of the
rest of the nation -- and worse than many developing countries. Poor access to health care, and
inequalities in health and life expectancies, don't end at national boundaries -- or city limits.
Women everywhere lack basic services that could save their lives, and ensure their
health. But more significantly, women and girls don't have equal access to the tools of
opportunity that could transform their lives. Education is inextricably tied to how women and
children achieve progress -- including better health. And the greatest literacy gaps existing in
such places as Western Africa and south-Central Asia -- where there are also some of the highest
rates of maternal deaths. It should come as no surprise that children of illiterate mothers are
twice as likely to die as those with educated mothers.
But women can't make progress in either their social or economic status unless they have
other opportunities as well. For too long, women have been denied the opportunities of jobs
and credit, legal protections, and the right to participate fully in the political life of their countries
all of which are the basic building blocks for a healthy and productive life.
Three years ago, when I addressed the World Health Organization in Beijing, I said that
women's rights are human rights, and human rights are women's rights. And I believe that now,
more than ever, it is a violation of human rights when women are denied skilled health workers
during child birth; that it is a violation of human rights when women are denied the right to plan
their own families; that it is a violation of human rights when the leading cause of death
worldwide for women between 14 and 44 is the violence they are subjected to in their own
homes; that it is a violation of human rights when women can't get the education they need to
ensure they and their children can lead healthy, productive, and engaged lives.
As long as these discriminations and inequities remain commonplace around the world,
then the potential of the human family to create a peaceful, prosperous, democratic world will not
be realized. But if we can apply the the force of international treaties and national constitutions
that address basic human rights to ensuring safe motherhood and healthy children -- and if we
can demand that governments address these underlying causes through political and legal
remedies as well as imposed health initiatives -- then, and only then, will we fulfill the
extraordinary promise of this time. Then, and only then, will every woman be treated with
dignity and respect, and every child be loved and care for, and every family have a healthy and
strong future.
I want to conclude my remarks this morning with story from my recent trip to Africa.
That trip was an extraordinary opportunity for me to see the flowers of progress and democracy
take root in even the smallest village, in even the poorest of countries. And wherever I went, I
heard the women of Africa singing. They sang as they cared for their children, as they wove
their baskets and shawls, as they turned shanties into homes, as they rebuilt their lives.
In Senegal, a group of women I met with from the Malicounda Biambara village, have
done something remarkable. They had decided that female genital mutilation -- considered a rite
of passage for all girls -- had harmed their daughters' bodies and spirits for too long. It was time
to end the hemorrhaging, and the infection, and the AIDS, and the childbirth complications
caused by this deadly tradition. And that's what they did.
Using a skit that they showed me, these women educated their religious leaders, their
husbands, and their neighbors. They banned the practice -- and are now inspiring others to do the
same. Just last month, 13 villages, representing 8,000 people, joined together to end genital
mutilation in their communities. And now President Diouf has called for a new law to abolish it
throughout the country.
When I asked one woman what drove her and the others to change such a deeply held,
long standing practice, she replied simply: "We studied human rights, and particularly the right
to health."
Thank you for this opportunity to join you on Women's Health Day, but most of all, for
your ongoing work to make safe motherhood a reality for every women and girl, in every nation
of the world. For me, the story of these Senegalese women is the story of how much progress has
been made in promoting the health and well being of women around the globe, and how far our
messages have traveled about the importance of women rights to open and democratic societies.
But it is also a stark reminder of how much work remains to be done. I thank you for your
accomplishments on behalf of women and children around the world -- but I thank you more for
the work that you will do in the months and years ahead to ensure safe motherhood is a universal
human right.
JUDY MANN
Safe Motherhood: A First Step in Development
T
wo significant shifts have occurred in
the third involves the quality, availability and
international development efforts.
sustainability of basic health services; and the
The first is an agreement reached by
fourth, the core circle, holds maternal health
major funders and nongovernmental
services.
organizations that women are at the center of the
These were patterns that emerged during
development process.
successful efforts in Malaysia, where women do
As World Bank President James Wolfensohn
not have legal barriers, according to Datin Seri Dr.
put it as part of his remarks during the World
Siti Hasmah, its first lady, who spoke at the
Bank conference on Safe Motherhood this week:
conference. Taboos were overcome, and family
"If you educate a woman, you educate a woman
planning has been stressed during the past decade.
and a family. If you educate a man, you educate a
Today more than 95 percent of women seek and
man."
receive pre- and post-natal care, and 95 percent
The second shift has occurred in the capital flow
had births that were assisted by trained personnel.
into developing countries. Aid from donor nations
In another address, Crispus Kiyonga, minister
fell from $40 billion to $37 billion from 1996 to
of health in Uganda, noted its successes in
1997, as developed countries tightened budgets
increasing contraception use.
and cooled to the strategic importance of
He also made the point that the Ugandan
international development now that the Cold War
parliament has 50 female members, that the vice
has ended. The biggest players now are
president is a woman and that there are several
private-sector companies, whose investments
women in the cabinet. After the country started to
went from $247 billion in 1996 to $256 billion last
pull itself together in 1986, he said, there was "a
year.
deliberate political decision" to encourage women
Wolfensohn made it clear that important
to become involved in the power structure, and
players in the private sector have joined a 10-year
the women's vote since then has become
partnership of governmental and nongovernment
particularly influential.
agencies. Among them are Merck & Co.
Hillary Rodham Clinton told a wonderful story
pharmaceuticals, which has donated Invermectin,
from her recent trip to Africa. The women of a
a drug that Wolfensohn says "has all but
village in Senegal had joined together to ban
eradicated" river blindness in Africa, and Johnson
female circumcision. "They have decided that
& Johnson, which recently announced
female circumcision, considered a rite of passage
distribution of a drug that fights parasites
for all girls, had harmed their daughters' bodies
common in Central America.
and spirits for too long," she said. "It was time to
What remains lacking is a fundamental political
end the hemorrhaging, and the infection, and the
will in many of these countries to make the health
AIDS, and the childbirth complications caused by
of girls and women central to development
this deadly tradition.
planning. "People don't care," he said. "As I travel
"Using a skit that they showed me, these
around talking to ministers, conversations about
women educated their religious leaders, their
health and safe motherhood are very rare."
husbands and their neighbors. And as a result,
Despite a decade of international efforts by such
they have banned the practice of female
groups as UNICEF. the World Health
circumcision in their village, and now in 13 other
Organization, the World Bank, the U.S. Agency
villages as well.
for International Development. the International
"When I asked one of the women in this small
Planned Parenthood Federation and the
village what had driven her and others to try to
Population Council, maternal mortality is now
end such a long-standing cultural practice, she
estimated at between 585,000 and 600,000 a year,
replied simply: We studied human rights, and
an increase from earlier estimates, which were
particularly the right to health.
probably unreliable. Current estimates are
What is so clear from that story is that the lofty
probably not all that good either, though, since
concept of women's rights being human rights-
many rural deaths are never officially reported.
which Clinton articulated in a shot heard round
Motherhood has been made safe in some places
the world at the U.N. conference on women held in
but not others, said Richard Feachem, who directs
Beijing in 1995-has reached the women in
the health, nutrition and population programs at
remote villages, the women who need this
the World Bank. During the decade-long
assurance the most.
partnership, he said, "we've learned a lot."
What was also clear from this week's conference
He urged the representatives of organizations
is that some of the most important voices and
involved in the Safe Motherhood effort to think
institutions in the world of development are
about the objectives as four concentric circles: The
committed to ending the scourge of maternal
outer one involves the empowerment of women in
deaths from unsafe abortions, lack of family
their families, villages and governments; the
planning, infections, obstructed delivery and other
second one holds the development process in
avoidable causes. Whether the resources will be
general, the establishment of a country's
there wasn't clear, but they certainly should be.
infrastructure, housing, clean water, sanitation;
This is an effort whose time is way overdue.
The Washington Post
FRIDAY, APRIL 10, 1998
THE KELIAKLE SOOKCE
By Ann Gerhart and Annie Groer
Four Lovebirds
Are Having
A Ball
A
h, spring. Ah, romance. Love was
much in the air at Wednesday night's
cocktail kickoff for the Washington Opera
Ball.
The fete at Anderson House, off Du-
pont Circle, was for Sir Christopher Meyer,
the British ambassador, and his relatively
recent bride, Lady Catherine, who wed on
Halloween. The Meyers will host the June
5 black tie fund-raiser at their Embassy
Row home.
"I think this ball may be specially
blessed because helping run it are two
sets of newlyweds,' Ambassador Meyer
told some 200 opera lovers, including en-
BY 10M
Patrick Ewing "in the paint" with 10-year-old Pernell Dongmo.
voys from the 35 nations who will host
pre-ball dinners.
While much of social Washington has
Knicks Star Patrick Ewing Paints the Town
met the Meyers, many at this soiree got
There was plenty of dribbling
and his own book, "In the Paint
their first glimpse of another pair of love-
going on when Patrick Ewing visited
With Patrick," a work-in-progress
birds: the opera ball general chairman for-
the National Museum of American
for young artists and their parents.
merly known as Betty Knight Scripps and
MARK FINKENSTATOR OR THE WASHINGTON POST
Art yesterday, but it involved
my mom and dad didn't
her new husband, investment banker lere-
Placido Domingo, in back, shares a laugh with the giddy British ambassador and his wife.
paint, not a basketball.
encourage me, I probably would
my Harvey.
The New York Knicks center,
have stopped," said the
"I don't know if should introduce her
And, perhaps, never so busy. Since
And what might be the secret to such
who majored in fine arts while a
seven-footer, who started drawing
as Betty, Elizabeth or Mrs. Jeremy Har-
their Valentine's Day marriage in the Do
bliss (beyond the obvious means to pay
basketball phenom at Georgetown
as a kid in Jamaica.
vey," said artistic director Placido Domingo.
minican Republic, they 've honeymooned
for it)?
University, was back in town for a
Ewing, his right wrist wrapped
For the record, and for the moment,
in Hawaii and visited London (Harvey is a
"We're both brats," Harvey said, noting
"painting party" with students
in a blue bandage from a Dec. 20
she's Elizabeth Scripps-Harvey and semi-
Brit). They're booked on an African safari
that they're only children with much in
from the District's Thompson
injury, confessed it had been a long
giddy.
in May, and after the ball it's back to Brit-
common. "Tonight we are trying to be
Elementary School, reports The
time since he was in a museum:
"It's wonderful. I've never been so in
ain to see the races at Ascot, tennis at.
grown up, but most days we're
Post's Sylvia Randall.
"I'm not really able to enjoy it, he
love in my life," she told The Post's Rox-
Wimbledon and maybe rowing at Henley
somewhere between 11 and 13 years old.
Ewing plugged the museum
said. "I'd be considered one of the
anne Roberts.
before a rest in the South of France.
It's amazing fun."
exhibit "Time Out! Sports in Art"
artworks" by fans.
NOWYOU RNOW....
And now, a multi-culti roundup
they also drew some jocks, includ
Opera legend Luclano Pavarotti
ing Redskins Gus Frerotte and Dan
The Washington Post
will perform with the Spice Girls, Cel.
Turk, as well as Baltimore Ravens
ine Dion, Jon Bon Jovi, Stevie Wonder,
quarterback Jim Harbaugh and a
Natalie Cole and Trisha Yearwood at a
clutch of D.C. United players.
FRIDAY, APRIL 10, 1998
benefit concert for Liberian chil-
President and Mrs. Clinton attend
dren, Reuters reports.
ed a Wednesday night salute to phi-
The June 9 concert for kids af-
lanthropist Paul Mellon and his late
fected by a decade of civil war is the
father, Andrew Mellon, who helped
third annual benefit for the Pava-
build the National Gallery of Art.
rolti & Friends Liberian Children's
Clinton first came to the museum
Village. It will be held in his home-
as a Georgetown University stu-
town of Modena, Italy.
dent 30 years ago, and returned as
.
Hootie & the Blowfish had lots of
Arkansas governor by playing
lamily and friends to cheer them on
hooky from National Governors
at the Bayou Wednesday night. But
Association meetings here.