Maternal Health Still A Major Global Issue

NEAL CONAN, host:

This is TALK OF THE NATION. Im Neal Conan in Washington.

And if you tuned in for a conversation with Anthony Bourdain about his new book, "Medium Raw," well, we regret the writer was unavoidably detained. We're trying to reschedule that conversation, hopefully next week. Stay tuned for that.

Each year, hundreds of thousands of women around the world die during pregnancy and childbirth, the great majority in developing countries, where complications from pregnancy are all too often endemic.

Now a study published in the British medical journal The Lancet gives reasons to cheer. Researchers found the first significant drop in maternal mortality in decades, from more than 500,000 a year in 1980 to just over 300,000 annually in 2008.

Later this hour, former Irish President Mary Robinson will join us to talk about progress toward Millennium Goals towards women's health. But first, NPR correspondent Brenda Wilson is here to tell us more, and we want to hear from you.

If you've worked in women's health, tell us your story. 800-989-8255 is our phone number. Email us, talk@npr.org. You can join the conversation on our website. Thats at npr.org. Click on TALK OF THE NATION. We'd be particularly interested to hear from those of you who have worked on this issue overseas and see what tell us what changes you have seen.

NPR correspondent Brenda Wilson joins us here in Studio 3A. Brenda, nice to have you with us, as always.

BRENDA WILSON: Hello, Neal.

CONAN: And what's responsible for this drop?

WILSON: It's sort of two-pronged, I would say. I mean, one is that, yes, there's a real drop, but also there are better measurements of what's going on. So for some time we've been thinking that nothing has been happening, actually.

CONAN: Well, it seemed to be half a million year these...

WILSON: Forever and not going down and never changing, and people saying, you know, we've got to turn this around. And so you had this institution in Seattle that just simply went out and looked at census data and looked at vital statistical registration, went and interviewed families, mothers, and talked to people, did very lengthy interviews, looked at as much data as they could possibly do.

You know, I think they said there were, like, about 16,000 documents, the people who had that study in The Lancet, and it turns out things were not as bad as we thought. Instead of UNICEF, the United Nations was already reporting a decline from, say, 11.9 down to nine million, okay, and they found that it was even lower than that, 7.7 million children dying each year.

CONAN: Still terrible, but...

WILSON: I mean, you know, that's still terrible but a lot more improvement than we thought. Also, the same situation with mothers. We've been saying 500,000 for years. It turns out it's 340,000.

And what's going on - of course you've got Bill and Melinda Gates, you've got the Global Fund to fight TB and malaria. You've got the United States PEPFAR program, the President's Emergency Plan for AIDS Relief, that was announced in 2003.

So you have this huge surge or influx of funding primarily in response to the AIDS epidemic that brought a certain kind of focus on major infectious diseases in these countries. So I mean, it all depends on whether you want to talk about material mortality or child mortality.

Actually, in the case of mothers, I think it was how they dealt with mothers who were delivering and giving birth. In places like Asia, you know, real sort of concerted efforts to train people to help women who are giving birth, because most of the time many of these women live in very remote areas. They do it all by themselves. Often they're very young, they're totally unprepared for child - giving birth or having children. Their nutrition isn't always great. So you've got food programs, you've got a lot more support going into assisting women.

So the sad part of that is that you probably would've seen even more progress for women if it had not been for HIV and AIDS. It probably slowed down maternal mortality, improving it by about 60,000 women.

Now if you look at the situation for children, you're talking about the three main killers and what changed there. The main thing that kills children is pneumonia, diarrhea, malaria.

And some of those they've been able to affect essentially by immunization, better immunization - let's say diphtheria vaccinations. You had Haemophilus influenza vaccination. Oral rehydration. One of the biggest killers of children is I'm sorry, one of the biggest killers of children is for some reason I'm drawing a is measles.

CONAN: Measles.

WILSON: I think we forget that here, and the reason I draw a blank is because in the United States...

CONAN: This is hardly a problem.

WILSON: We don't think of measles killing children, but immunization has helped to bring that down significantly, as well as oral rehydration.

CONAN: Well, on both of these issues, we've seen two countries that were among the poorest countries in the world, China and India, in the past 10 years their economies have developed rapidly. There are still an awful lot of very poor people in India and a lot of very poor people in China, but those proportions have begun to change drastically. Has that had an impact on the health of women and children?

WILSON: I'm going to I'm the health reporter, and I'm not simply looking at the economic impact. So I'm going to have to bow out of that question myself.

CONAN: All right. Then we go on to the questions of, if you're saying, essentially our statistical, our ability to gather statistics has improved, does that suggest we are not making progress on controlling the actual death of women?

WILSON: Oh, no, no, no, no, I wouldn't say that. As a matter of fact, we are looking at fairly early statistics. I mean, when you consider that this funding went in in 2000, and some of the things that we are now seeing an impact we're not it's not registering everything that's being done.

For example, in 2008 and 2009, more recently, many of these countries have been sort of, oh, there's been huge campaigns to get malaria bed nets into areas where the parasite is endemic, to protect children against infection, and we don't really know what impact that has had, because that's a fairly recent event, fairly recent phenomena. The numbers could be even lower than we think.

CONAN: We're talking with Brenda Wilson about new studies on the numbers of deaths of women and children around the world and how they measure up to the Millennial Goals, the Millennial Development Goals, and there is good news. 800-989-8255. Email us, talk@npr.org. We want to hear especially from those of you who have worked overseas. We'd like to hear what you have seen wherever you were. We'll start with Burt(ph), and Burt's with us from Santa Rosa in California.

BURT (Caller): Yes, I worked in Kenya with the Peace Corps in '93 and '96, and during that time I worked in conjunction with a European team that was doing research in statistics on septic abortion attempts, women dying trying to abort babies any way they could.

In Africa for one year the count was 16,000 women. The National World Health Organization has better stats, but I'm curious. This is parallel to the circumstances of pregnancy, but the death of women in this particular area is pandemic, and I'd like to know if we have more information about that. Thank you.

CONAN: Thanks, Burt.

WILSON: I mean, I think that one of the things that's been interesting is that over the last I'd say eight years or so we've had a huge dispute globally over reproductive health services, a period where the U.S. government did not fund family planning because of an interpretation of what, in fact, family planning meant, and therefore not providing funds in areas where they thought it meant that abortion services would be provided, even if even though services were provided to women after a failed attempt at an abortion.

So it's a but in the meantime, you family planning was essentially flat-funded for eight years. That meant that women didn't have access to the means to prevent unplanned pregnancies.

CONAN: You mentioned PEPFAR before, the president's effort to reduce AIDS, particularly in sub-Saharan Africa. There has been something of a controversy as the Obama administration has chosen to increase funding for that program by a smaller amount, I think five percent or so, and to put more emphasis on other programs, indeed these programs to work to save infectious diseases for women and children.

WILSON: Yes, but in the meantime, as I'm sure someone from the administration would point out, that the administration continues to increase funding.

There's a huge dispute over this, over whether it has as yet had an effect or impact. In some of the places it's very anecdotal. It's not clear. It is clear at some point that the economic slump around the world - a lot of countries have pulled out - is going to have an impact.

So you get countries like Japan, who have not been able to contribute, but the U.S. and the United Kingdom and Germany have essentially maintained their funding, and there are a lot of other things going on behind the scene that may affect the flow of drugs into a country, the supply of drugs.

So you've got different groups operating, and perhaps the drugs are not getting from one group to another group, and it looks like a shortage. Although people are saying a shortage of these HIV/AIDS drugs are imminent, it is not clear that that has, in fact, happened yet.

So it's not clear that flat-lined funding, as people are complaining, has yet had that kind of an impact.

CONAN: Let's hear next from Nicole(ph), Nicole with us from Colorado Springs.

NICOLE (Caller): Hi, I just had a question. I was living in Japan for about a year and heard accounts of women actually not bearing children, and you know, due to globalization or what may be - Italy was having the same accounts of women not being as interested in having families. And I was wondering how that actually impacted the statistical data as far as mortality with child bearing if not as many women were actually having children.

CONAN: You hear those statistics in Europe, Brenda, certainly in Japan, which she mentioned. But those are developed countries.

WILSON: You're talking about developed countries and about 90 percent of maternal mortality. You do hear of increased rates of maternal mortality in the United States. Ive not been able to establish or ascertain the reasons for that or if, in fact, to what extent that is true.

But primarily, when you're talking about maternal mortality, you're talking about developing countries, the rates are, you know, not as bad even in middle-income countries such as Brazil, you know, China, India. India is a different case because you've got mixed populations there, very poor and middle class.

CONAN: What about Russia and, again, the population there is - many women there are choosing to have fewer babies?

WILSON: You - the same thing. Yes. It's sort of, I would imagine, in Russia - I'm not going to speak as an expert there, that it's a mixed situation. You've also had a collapse of a public health system. So an economy that is beginning to rev up, but I don't think it's the same situation as it is in developing countries. Ninety percent of these mothers' deaths are occurring in places, you know, in Africa, Southeast Asia, Asia and places like that.

CONAN: Thanks very much for the call, Nicole.

NICOLE: Yep. Thanks. Take care.

CONAN: Bye-bye. Let me ask you also a question about politics, which reared its head as these new numbers came out, again from over 500,000 a year to, well, about 340,000 a year. This was in advance of this meeting here in Washington, D.C. that's taking place even as we speak. And there were some women's health advocates who said, wait a minute, this is not helpful. This undermines our cause.

WILSON: I've heard both sides of that argument. And I think I'm more persuaded by the other side of that argument, which is I think that the absence of progress. If you continue to put money into a situation and it doesn't improve, I think it can defeat the purpose of the funds. So I think to hear that, in fact, all of the money that has been contribute to assisting global health programs is, indeed, having an impact. From others, I've heard that it energizes people, okay? It - you can do good. It will have an effect.

CONAN: We know what to do.

WILSON: We know what to do. It gives you an example. You go - you sort of copy the efforts in different places that have worked. You repeat them in other places.

CONAN: This was, apparently, efforts - calling the editors of the Lancet in hopes that they would, I guess, delay publication of these studies until after these meetings.

WILSON: Yes. But, I mean, I - one, I don't think it's a question of UNICEF's numbers not being correct. Theyre - these are estimates anyway, essentially. What I'm talking about is the way that the numbers are gathered and put together, their statistical analysis, it's not so much that UNICEF is wrong. It is that given the information they had, this is the conclusion that they arrived at.

These are not people that are trying to deceive anybody. It's simply that Institute of Health Metrics and Evaluation in Seattle had basic, better documents and had spent some time - they'd gone back to 1970 and looked at trends over time so that you would see changes and you'd have a better picture of what's going on.

CONAN: We're talking with NPR correspondent Brenda Wilson about new statistics published in the Lancet, the respected British journal that suggests that women's health is improving around the world. Those women who died in pregnancy or child birth is down from an estimated over half million per year to about 340,000 per year.

In a few minutes, we'll also be joined by Mary Robinson, the former president of Ireland, the former UN commissioner for human rights, on this question.

You're listening to TALK OF THE NATION from NPR News.

And let's see if we can go next to - this is Miriam(ph), Miriam with us from Tallahassee.

MIRIAM (Caller): Thanks for taking my call. I'm calling to talk abut what is happening in this country with maternal mortality because while 10 percent of the maternal deaths internationally are in developed countries, I think it's important to talk about the fact that at least in the state of Florida, where we have a fabulous, very comprehensive maternal death review process, we always are asking the question, if the woman hasn't been pregnant, would she have died? We do see much higher rates than we thought we would.

We have extended our timeline out to 12 months after the completion of a pregnancy, and we find that the vital stats numbers, although improving, don't completely correlate with what we see when we did the death review process. We know that quite a bit of this is skewed so that African-American women are dying at much higher rates than women of other races and it is across all economic and educational levels. So, being a middle class or upper class, graduate school-educated African-American women is not protective.

We also see that obesity is significantly adding to maternal deaths as is our increasing C-section rate. We know that there are more deaths due to more C-sections. We particularly see that with repeat C-sections where there are placental problems.

And I'm thrilled that we have so much attention based on this internationally. I also want to make sure that we don't lose the focus on the national, local issues that we have because they are also significant and, I think, more significant than people have assumed. So thanks very much.

CONAN: And, Miriam, thanks very much for the phone call. The statistics she cites are consistent with what we see in the report. Indeed, I think the numbers cited were that African-American women are four times more likely to die in pregnancy and child birth than white American women. Nevertheless, it also points to the fact that though there has been measurable significant progress, there is an enormous amount left to do.

WILSON: Yes. I would agree. I mean, I think - I don't think anybody is going to feel complacent at hearing, you know, I hope they won't -300,000. I think one of the things that's really good about this is that many governments are beginning to recognize that the health of their economies, the health of their countries, the health of their societies depend upon the health of women and children.

CONAN: Brenda, as you look at these numbers, are we going to - the World Health Organization still uses the old numbers. Are they doing a new study?

WILSON: I think you know what, I actually dont know. I'm going to just - I think the best thing to say here is I dont know.

CONAN: All right. We're going to ask Brenda to stay with us. And when we come back from a short break, we're going to be talking with Mary Robinson, the former president of Ireland and the former U.N. commissioner for human rights as she's here in Washington, D.C. for a meeting to measure progress towards millennial development goals on this and other issues.

If you'd like to join the conversation, our phone number is 800-989-8255. Email us, talk@npr.org. Stay with us.

I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

(Soundbite of music)

CONAN: Right now, we're talking with NPR's Brenda Wilson about women's health and maternal mortality rates worldwide. If you've worked in women's health, tell us your story. Wed especially like to hear from those of you who have worked overseas. 800-989-8255. Email us, talk@npr.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.

Mary Robinson, former president of Ireland, later served as United Nations High Commissioner for Human Rights, is in Washington this week to attend an international conference focused on women's health.

And while President Robinson says the new data look like good news, it's far too soon to celebrate when too many countries still struggle to reduce maternal deaths.

Former President Robinson, currently president of Realizing Rights: The Ethical Globalization Initiative. And she's also with us here in Studio 3A. Thanks very much for being with us on TALK OF THE NATION today.

Ms. MARY ROBINSON (President, Realizing Rights: The Ethical Globalization Initiative): Its a pleasure.

CONAN: And also Brenda Wilson is still with us. And to what do you attribute this progress?

Ms. ROBINSON: I think it's good actually that we are seeing some progress because I was attending a similar conference to this one here in Washington, Women Deliver in London three years ago. And the figures were really very stark and they weren't budging. And that's not good because people dont get energized when something is not improving. And so, we are seeing that the situation is improving.

I think the first thing that has happened is that women's health is getting more priority. I was actually very pleased to hear some of the previous discussion because you're airing a subject that's - we've always said needs more focus of attention. It's enormously important because girls and women's health is so important to the development of the whole society. And that now has become much more clear to presidents and prime ministers, as well as ministers of health in many countries in the world.

But, you know, before we read too much into some improvement in the figures, I would say two things. I would say only 23 nations are likely to reach the goal of MDG5 and of maternal health and tackling maternal mortality.

You know, a mother dies every minute from complications at birth because there was no birth attendant and nobody who knew how to address complex obstetric problems. And for every mother who dies, 20 suffer terrible injuries to their womb. It may be from botched abortion, which is all too prevalent, unfortunately, or other complications. And so, we have that hidden problem of women who instead of giving birth with joy, find that it became a terrible experience for them.

CONAN: But does the progress suggest that in the countries that are not showing progress, they can look at models and say, right, if we do what they did there, we can see comparable progress?

Ms. ROBINSON: I think it's fair to say that we do know what works. But the problems are complex. You need a health service that reaches everyone in rural areas and in more remote areas, that you have health workers, midwives, those who know what to do at the birth. But it's not just a health issue. This is where my human rights voice comes out.

There are so many other barriers. I was on a panel a short while ago with a young Nigerian woman who's HIV positive. And she's talked about the barriers in her case. But she also, as a married woman, said that so many married women need the permission of their husbands to leave the home. So if the husbands away and the woman is there, and she feels that she's about to give birth, she cannot leave the home.

The cultural problems, the early child marriage. There are thousands and thousands of girls who are married at the age of nine, 10, 11, who become pregnant at the age of 10 or 11. And, of course, many of them die.

And the figures in countries like Sierra Leone are really stark. One in eight women die having become pregnant. So to become pregnant is a real risk factor. And we have to ensure that poor countries have support in strengthening their health systems, in retaining their health workers, in providing the kind of care, but also in removing some of the discrimination in barriers.

CONAN: And let's...

WILSON: And in countries like Mali, for example - I was speaking with a doctor from Mali at the Women Deliver Conference here in Washington, D.C. And she was talking about how they have recruited the grandmothers, because the older women, you know, they're the ones who uphold the traditions. And if they speak, people listen. So they have recruited them to sort of inculcate the value of getting the young girls to delay marriage, to, you know, put it off until, you know, they were older, till they were 18.

The society now has a law that is not necessarily followed. So does Ethiopia. Many countries are adopting laws, but they aren't always followed. So they've had to recruit members of the community that have standing to see that the laws are carried out or that, you know, that they're supported.

CONAN: Let's get a caller in. This is Veroon(ph) - I hope I'm pronouncing that correctly - in Buttonwillow, California.

VEROON (Caller): Hi, there, Neal. I was hoping that the speaker could comment about the importance of potable water during the birthing process and also for nutrition.

CONAN: Clean water: How important is that, Mary Robinson?

Ms. ROBINSON: Absolutely, yes. And there was a very important report recently about the social determinants of health, and it talked about water and good nutrition. And these are all factors, as well. And I think by - from my point of view, we talk about the human rights approach. We talk about women's rights, or human rights, which was the message from the famous Beijing conference some years ago. But...

VEROON: And it's also the quickest way to increase nation's GDP, correct?

Ms. ROBINSON: Very much so, and that was the point I was really emphasizing. I'm glad you brought it out.

VERNOON: I think that was...

CONAN: Yes.

VERNOON: What we discovered was that the most significant factor in development was women's health.

Ms. ROBINSON: Yeah. And then, beginning with girls' education, the girl child. I'm very glad that so many organizations are now coming together, a coalition about the adolescent girl, because she was the one who was unlikely to go to school if only one or two children could go - if there were school fees, for example, would be taken out of school, or, indeed, because she was beginning to have her period and there were no toilets that were private in the school, she would be embarrassed and drop out of school. Or she would be taken out of school to look after a relative - so the importance of girls staying in school and getting a quality of education that empowers them.

CONAN: I wanted to follow up, though, on something we were talking earlier with Brenda about, and that was the change in focus of some international donors - and, indeed, some governments - towards issues like women and children's health, but at the expense, some say, of focus on HIV/AIDS. And these are not two different things, necessarily.

Ms. ROBINSON: That's certainly has been something that the Women Deliver conference has really addressed. So, you're right. People are concerned about that. Of course, there's a complete interconnection, and we need an integrated approach.

If you look at the situation of girls in countries of sub-Saharan Africa, we know the sad figures, that girls can - between 15 and 24 are sometimes three times, four times, five times more likely to become HIV positive. And the reason for that is a power imbalance.

The girl doesn't feel she can say no. She feels that - she has no self-respect because she's not brought up to respect herself and - if she hasn't had access to education. And, you know, teachers look for sex for grades and uncles try to cure themselves of AIDS with them. And so there is that interconnection. And then there's the mother-to-child transmission. There's so much - we mustn't address - we must address holistically the health issues.

CONAN: Right. And what you said about uncles...

Ms. ROBINSON: Yeah.

CONAN: ...addresses the myth that...

Ms. ROBINSON: Yeah. Absolutely.

CONAN: ...to have sex with a young girl will cure you of AIDS. But...

Ms. ROBINSON: And part of the tension in this issue is kind of how do you reach that girl, given that, in many countries, people don't want to go to the HIV/AIDS center. So that - the idea that some people are resistant to, but - is integrating all these services, in other words, improving the health system, and therefore being able to reach people whatever their health issue may be, whether it's the need for family planning services or reproductive health services, making sure that the HIV/AIDS services and all of those health needs are in one place so that people don't have to avoid the HIV/AIDS center, because it'll be just wherever they go.

Some fear that it means funding is going to be taken away from treatment and for - you know, we have four to five million people now who are alive because there has been treatment made available for HIV and AIDS.

CONAN: One last call. We'll go to Julie, Julie with us from Shiprock in New Mexico.

JULIE (Caller): Hello?

CONAN: Hi, Julie. You're on. Go ahead, please.

JULIE: Hi. I just want to say I'm a certified nurse-midwife. And I work a lot for a great organization called Partners in Health, mainly in Haiti. And actually, Partners in Health did just that. It had an integrated health system where you could go and get all your health care: your children, HIV, women's health.

And that's my comment, was that I think you really need to be an established part of the community that you're working in. And you need to be present and the clinic needs to be opened seven days a week. You need to see everyone who comes.

I mean, we would see patients, you know, until 9 o'clock at night because they traveled five hours to get there, and you have to see them. They have to trust you and believe that you care about them. We did home visits. We, you know, we would sent community health workers out to see them. And we got great responses. And I just - we just really need to work in a community, stay there. You can't do this two-week trips and leave.

And then the last comment about statistics...

CONAN: Quickly, if you would.

JULIE: We worked - we got grants from PEPFAR and Gates, and we developed an online database system where we had to put in the information because of these grants that we got. It was a pain, but it was great because the workers had to put in the data themselves, and they saw their work and they saw these statistics and they saw where they were doing really well. And they saw where they worked, and we work on improving.

CONAN: Julie, thanks very much. Yes, Mary Robinson.

Ms. ROBINSON: I was just going to say that I'm a great admirer of Partners In Health, and also Paul Farmer, their founder, is not only American. He's also very Irish. And I...

(Soundbite of laughter)

Ms. ROBINSON: We introduced him to Ireland, and we - but, in fact, the reason why it works is - it is that holistic, human-rights approach that, you know, sees it from the perspective of all the issues that have to be addressed: safe water, nutrition, the barriers, land rights, early, child marriage, all of that.

CONAN: And it shows us that we do know what works and how to apply it...

Ms. ROBINSON: In other words...

CONAN: ...but then we think about Haiti, and we also understand huge problem and much, much, much work left to go. Julie, thank you very much for the call.

JULIE: Thank you.

CONAN: And we'd like to thank our guest, Mary Robinson, former president of Ireland, the former U.N. commissioner on human rights and now president of Realizing Rights: The Ethical Globalization Initiative, and honorary president of Oxfam International. Thank you very much for being with us today.

Ms. ROBINSON: Thank you. A pleasure.

CONAN: And our own Brenda Wilson, here with us in Studio 3A. Brenda, thanks, as always.

WILSON: Thank you, Neal.

CONAN: You're listening to TALK OF THE NATION, from NPR News.

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