A call for consensus and cooperation to resolve differing estimates of abortion-related deaths

29/08/2016 Comments Off on A call for consensus and cooperation to resolve differing estimates of abortion-related deaths

This article, in press, is about the difference between estimates of maternal deaths from unsafe abortion from the World Health Organization and those from the Institute for Health Metrics and Evaluation (IHME), USA, both published in 2014 in two different Lancet journals. The article, co-authored by Iqbal Shah, Carla AbouZahr and me, is in the International Journal of Gynecology & Obstetrics (IJGO). The article begins:

“The publication of two papers with widely differing estimates of abortion-related deaths has caused concern and confusion among individuals who work on mortality and morbidity related to unsafe abortion. Both papers claim to offer correct estimates based on robust and rigorous methodologies. We wish to highlight this issue and discuss how the differences might be overcome.”

If you subscribe to the IJGO you can find it here: http://dx.doi.org/10.1016/j.ijgo.2016.05.012

It has taken submissions to three journals, Lancet, WHO Bulletin and IJGO, over a period of 11 months, the first two unsuccessful, to have this published.

The likelihood that the IHME and WHO staff responsible for their respective estimates on deaths from unsafe abortion will sit down together to resolve their differences is anyone’s guess.

Meanwhile, we are all left not knowing whose figures to use. I took a personal decision, based on the arguments made in our article, to go with the IHME figures, as there is no other way of resolving this. I am using IHME’s estimate that 43,684 (14.9%) maternal deaths in 2013 can be attributed to unsafe abortion (Lancet 2014). I am also sharing the Guttmacher Institute’s estimate that there were 56.3 million abortions per year globally for the years 2010-2014 (Lancet, 11 May 2016), as few people seem to be aware of this new estimate either.

Based on my own (limited) knowledge of other people’s articles and presentations, and from what I’ve seen quoted in the mainstream media, the out-of-date WHO figures for 2008, published in 2011 — 46 million abortions with 47,000 abortion-related deaths annually — are still commonly being used. For those who are aware of the conflicting WHO and IHME estimates, few will have the expertise to choose between the two methodologies, but the sad part is, that shouldn’t be necessary.

At the end of the article we say: “As the leader in global health, WHO has a constitutional responsibility to support countries in strengthening their health-information systems. Likewise, IHME has a stature commensurate with its technical expertise and generous funding. Surely it is incumbent upon both organizations to put their differences aside and reach a consensus on the method required to produce one set of estimates that are comparable over time and that everyone accepts as the best possible information to guide clinical practice, policy and program priorities. Yet they remain unwilling to do so. In the absence of a neutral body with comparable responsibility, we believe that WHO should insist that its experts invite IHME experts, and others who might be considered neutral, to reach an agreement on the way forward.”

That pretty much sums up what we had to say from an advocacy point of view. The article goes into more detail, and also on the methodological issues too.

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The Brazilian government pays compensation for a maternal death taken up by CEDAW – a decision that has global implications

14/09/2012 Comments Off on The Brazilian government pays compensation for a maternal death taken up by CEDAW – a decision that has global implications

Lisa Hallgarten, RHM

The Brazilian government has agreed to pay compensation for the death of a pregnant woman in 2002. The decision could have implications for governments around the world where women are dying from preventable deaths in pregnancy, childbirth and abortion. The Brazilian government’s move follows landmark decisions by the Committee on the Elimination of Discrimination against Women (CEDAW) in Brazil and Peru – reported in Reproductive Health Matters. CEDAW confirmed that all states have a human rights obligation to: guarantee good quality maternal health care; guarantee access to abortion when a woman’s mental or physical health is threatened by continuation of her pregnancy; and decriminalise abortion when the pregnancy results from rape or abuse.

The case of of Alyne da Silva Pimentel v. Brazil was taken up by CEDAW in 2011. Alyne died following a stillbirth towards the end of her second trimester of pregnancy as a result of misdiagnosis, inadequate treatment in her local health centre, failure of the centre to refer her for timely emergency obstetric care and inadequate care when she was finally referred. CEDAW found that she was a victim of discrimination because she was a woman, poor and of African descent. Following the CEDAW Committee’s recommendations, the Brazilian government has agreed to pay compensation for Alyne’s death in childbirth, and is to set up an inter-ministerial enquiry into where responsibility lies for the chain of events that result in a maternal death. It also plans to organise a seminar on the issue for lawyers and health professionals.

In the case of L.C. v. Peru, a young girl had been repeatedly raped by different men in her neighbourhood over a period of four years. At the age of 13 she learned that she was pregnant and made a suicide attempt which failed, but left her at risk of paralysis and in urgent need of spinal surgery. She was refused the surgery she needed because she was pregnant, and was also refused an abortion. Three months later she miscarried and doctors agreed to perform the surgery. Unfortunately the delay meant the intervention was unsuccessful and L.C. is now quadriplegic. Peruvian law already permits abortion in cases where a woman’s health or life is at risk. CEDAW ruled that access to abortion in these cases should be guaranteed.

CEDAW’s findings come in the context of legal and civil actions around the world aimed at making governments accountable for women’s health and lives in pregnancy, childbirth and abortion. We hope that the announcement from Brazil that it will act on CEDAW’s recommendations may encourage Peru to do so too, and will  help to reinforce the fundamental principle that women’s rights are human rights.

Other cases highlighted in RHM

Alyne’s case and the negligent, callous and discriminatory treatment she experienced, has echoes in stories we have published from all over the world including the testimony of a doctor in a sub-Saharan African country on this blog. Papers in May’s issue of Reproductive Health Matters demonstrate that failure to provide good quality, equitable and accessible maternal health care is widespread. Increasingly however, lawyers, families and health professionals have had some success in holding their governments and health services to account.

In India an investigation into maternal deaths in Madhya Pradesh documented lack of accountability, and discrimination against poor women, particularly tribal women. However, the authors report that since presenting the report some of their recommendations have been taken up. In another article from India authors explore the successful legal case made for compensation and accountability for the death of Shanti Dev in Haryana State.

Another article reports on opportunities for progress that could be learned from the success of HIV activism in sub-Saharan Africa where health professionals and civil society activists have formed alliances to demand constitutional rights to health care for people living with HIV. A recent attempt by health activists in Uganda to use the courts to establish the constitutional rights of women to quality maternal health care failed, but the NGOs involved have promised to appeal…watch this space.

Read the full editorial of RHM’s recent issue Maternal mortality or women’s health: time for action

Making change happen is in the air

13/07/2012 Comments Off on Making change happen is in the air

Marge Berer

Editor, Reproductive Health Matters

Below, are excerpts from my editorial in RHM 20(39) May 2012. This issue is about reducing maternal mortality, but the more I reflected on it the more I realised it had implications for this week’s summit on family planning.

Making change happen is in the air, from the UN Secretary-General down to the most remote village… Yet, in certain ways, the world is moving backwards when it comes to dealing with women and pregnancy. Simone Diniz calls it a return to “materno-infantilism” – treating pregnant women like children who need looking after… Today, in much of the literature, all pregnant women are called “mothers” whether they’ve ever had a baby or not. Yet pregnancy has more than one outcome and is not only about women who “deliver”. It’s also about women who experience miscarriages, stillbirths, infant deaths, lack of access to contraception, unwanted pregnancies, unsafe abortions, and lifelong obstetric, reproductive and sexual morbidity. Yet these are nearly invisible in PMNCH these days, and safe abortion – an integral part of women’s right to decide the number and spacing of their children – may be made invisible in the new Family Planning Initiative as well…

The papers [in this journal issue] show that some countries are making serious efforts at strengthening and improving their health systems in relation to reproductive health care and maternity services. Based on data that show who is dying and why, they are making policy and programme changes, such as low-cost delivery services for poor and migrant women, opening new obstetric emergency care and referral centres in hospitals, training more health professionals, and providing health education for women, as in Shanghai (Du et al)…

Others are strengthening the whole public health system, especially in rural areas where most poor women live, ensuring better leadership and governance, increasing health workforce skills, supporting community-based health insurance, and increasing contraceptive services, as in Rwanda (Bucagu et al). They’re promoting peace, stability, economic growth, poverty reduction, improved primary education, better roads and communications, access to information on health and health services, and making health care free of cost for the poor, as in Cambodia (Liljestrand & Sambath)…

In contrast, in some countries, appalling, chaotic, uneven, negligent and abusive situations persist. Among the 22 million women each year who have unsafe abortions, adolescents suffer the most from complications and have the highest unmet need for contraception (Shah & Åhman). Custom, lack of perceived need, distance, lack of transport, lack of permission from husbands, cost, unwillingness to see a male doctor are still preventing women from seeking antenatal and delivery care, e.g. in northern Nigeria (Doctor et al), but in many places, these services barely exist anyway…

In the poorest of countries, women may have more pressing health needs even than for maternity care, e.g. in Haiti, where women identified access to any affordable health care, potable water, enough food to eat, any employment, sanitation and education as their most crucial problems (Peragallo Urrutia et al)…

Even more broadly, lack of national commitment has been identified as critical in 33 sub-Saharan African countries, as well as very low levels of public financing for health and health services (let alone maternity services), poor coordination between key stakeholders and partners, poorly functioning health systems with poor logistics for supply, distribution and management of essential medicines, family planning commodities, and equipment, and a chronic shortage of skilled health professionals (Ekechi et al).

In several South Asian countries, cash is being given to pregnant women to deliver in facilities, but some studies are finding, e.g. in India, that when women arrive, there is limited or no antenatal care, no birth attendants with midwifery skills, no emergency obstetric care in obvious cases of need, and referrals that never result in treatment (Subha Sri et al). And now, these same women have a sense of entitlement, and they are protesting.

Several governments in Latin America may be embarrassed to learn that their levels of budget transparency in spending on specific aspects of maternity care were found to be very low, and that they need better budgeting modalities, better health information systems and guidelines on how they might better capture data on expenditure, in order to track and plan local and national progress (Malajovich et al). Similarly, an assessment of cash transfer and voucher schemes designed to stimulate demand for services and reduce cost barriers to maternity care found increased use of maternity services in several south Asian countries, but also a need for more efficient operational management, financial transparency, plans for sustainability, evidence of equity and, above all, proven impact on quality of care and maternal mortality and morbidity (Jehan et al).

The papers [in this journal issue] describe a range of models for advocacy and taking action to expose violations of human rights, poor public health practices, absence of monitoring and regulation, failure to ensure national accountability for sexual and reproductive rights and to provide remedies and redress in the event of violations (Kismödi et al).

full editorial

Botched motherhood

11/07/2012 Comments Off on Botched motherhood

A poem by Tiro Sebina – featured in Reproductive Health Matters May 2012
You may not want to hear
About a woman who died
In labour in a hut

You may not want to hear
About an expectant woman
Who perished aboard
A donkey cart
On a bumpy road to an apology
Of a health post
With neither doctors on site
Nor drugs in sight

You may not want to hear
About an expectant woman’s fatal fall
Off a rickety bike
Pedalled by a drunken man
Terrified of Emang Basadi
Concerned about his name
Appearing on the birth certificate

You may not want to hear
About a woman who expired
Without knowing
She was targeted by grand visions
And millennium schemes

You may not want to know
About a woman too hapless
To grace dinner-conferences
Held in her name
At exclusive venues

Who wants to know
About the bungled chaos
Of a dead mother

Trends in maternal mortality 1990-2010: latest data

18/06/2012 Comments Off on Trends in maternal mortality 1990-2010: latest data

by Marge Berer

Editor Reproductive Health Matters

Thanks to the Millennium Development Goals and much work on the part of the UN, WHO, many governments and NGOs globally and nationally, the press and media are now highly attuned to what is happening as regards maternal mortality. An announcement by WHO on behalf of the United Nations of the latest global estimates, published in May 2012, showed that the trend in maternal deaths appears to be falling overall, and resulted in many newspaper articles sharing this very good news. The global data were as follows:

  • The number of women dying due to complications of pregnancy, childbirth and unsafe abortion decreased from 543,000 in 1990 to 358,000 in 2008, and 287,000 in 2010.

This excellent news masks the fact that there has been a lot of change in some countries and virtually none in others. Here are some of the details of those differences, taken from the report:

  • Deaths are falling quickly in East Asia but the reduction is attributed largely to China.
  • Southern African countries have seen the beginnings of a reversal, but sub-Saharan Africa (56%) and southern Asia (29%) accounted for 85% of the global burden in 2010.
  • India (19%) and Nigeria (14%) alone accounted for a third of deaths globally.
  • 40 countries (20 % of the total number of countries) still have maternal mortality ratios greater than 300 deaths per 100,000 live births.
  • Countries with the highest maternal mortality ratios were: Chad, Somalia, Sierra Leone, Central African Republic, Burundi, Guinea-Bissau, Liberia, Sudan, Cameroon, and Nigeria; Lao PDR, Afghanistan, Haiti, Timor-Leste – these are among the world’s poorest countries, many of which are also sites of conflict, war and other crisis situations, such as earthquakes and flooding.

In other words, many countries still have very high maternal mortality ratios, including two very large countries, which account for a large proportion of deaths. Moreover, there is a growing gap between countries where improvements have taken place and many of the poorest countries, where most women are still simply not benefiting. Furthermore, as the May 2012 edition of RHM shows, there are differences within countries and between women (according to socioeconomic status, rural vs urban status, age and marital status) that are sometimes great and must not be ignored. The paper by Shah and Ahman, for example, shows that unsafe abortion deaths remain high in many countries and that young women are at the greatest risk of death and complications from unsafe abortion. A study in Nigeria shows that women in northern Nigeria are at far greater risk of maternal death than women in the south of the country. Given that the primary aim of the Millennium Development Goals is to reduce poverty and the consequences of poverty, celebration is perhaps not yet in order. However, countries where improvements have clearly taken place, such as Rwanda and Cambodia, as shown in other RHM papers, certainly deserve credit for enormous efforts.

Limitations of global estimates of maternal mortality – Nepal

15/06/2012 Comments Off on Limitations of global estimates of maternal mortality – Nepal

The latest United Nations publication on global estimates of maternal mortality was released in May this year. Some of the news from this report is good, that despite big regional variations, overall maternal mortality is reducing at a global level.

One limitation of the estimates is that they fail to shine a light on the stark disparities between countries, some of which have made little if any progress, or within countries, for example between women living in rural and urban areas. They mask inequity in access for poorer women which characterises health service provision in many countries, and which remains a huge stumbling block to tackling the preventable causes of maternal death.

There is also concern that different estimates from a range of sources confuse the picture for those in the field; that the estimates cannot provide a comprehensive understanding of what works or how to explain reductions in maternal deaths – information which is essential if further progress is to be made;  and, most worryingly, that the perception of success in reducing maternal deaths may lead to complacency or neglect of the problem.

Nepal

In Nepal, maternal mortality has reduced from 770 to 170 deaths per 100,000 live births between 1990 and 2010, thus reaching the 75% reduction MDG target for 2015. The new estimates are only one of a series of different estimates released and published. The others were published in the Lancet and by WHO here, here and here.

These papers report different estimates of maternal mortality (calculated using different methods) relevant to approximately the same period of time. On the surface, the estimated reductions in Nepal should be reason for optimism, especially as all the estimates suggest a falling trend of maternal deaths in Nepal. But these new estimates have caused confusion and frustration in Nepal.

The confusion arises because the estimates do not agree, so it is not possible to say what the current level of maternal mortality is. Some people believe that the estimates report improbably low levels of maternal mortality and a larger than expected reduction over the last two decades, given the difficult geographical terrain, relatively low access to maternity services and variable standards of care in Nepal. Their frustration arises from the difficulty in interpreting these estimates to ensure that maternal and reproductive health services do not become neglected.

Maternal mortality is notoriously difficult to measure . For now, Nepal will have to deal with the uncertainty of the estimates, at least until the national demographic and health survey planned for 2016 provides more data for better estimates. Instead of debating what the actual level of mortality is or which estimate to use, what needs to be done is to draw on the situation to generate interest in finding out why the reduction is occurring. First steps have been made to do this , but more evidence needs to be gathered to build up a convincing picture of what changes are being experienced in Nepal. The reasons we find may not necessarily be what we might assume or expect, and will provide valuable lessons for other countries still striving to reduce maternal deaths.

A guest blog by Julia Hussein

Senior Clinical Research Fellow Immpact,
Scientific Director Ipact, University of Aberdeen, UK

Reproductive Health Matters

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