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Health: Maternal Health

Volume 723: debated on Wednesday 12 January 2011

Question for Short Debate

Asked by

To ask Her Majesty’s Government how they propose to meet Millennium Development Goal Five on improving maternal health and maternal morbidity.

My Lords, before I introduce today’s debate, it gives me great pleasure to congratulate the Minister, the noble Baroness, Lady Verma. Last week, the Prime Minister of India bestowed on her the high honour of Pravasi Bharatiya Samman in recognition of her work.

I thank the long list of distinguished noble Lords from all sides of the House who are taking part in the debate. That demonstrates the huge interest that your Lordships’ House has in the subject and signifies the need for a longer debate. It is a pleasure to note that the noble Lord, Lord Green of Hurstpierpoint, will make his maiden speech. I look forward to that. Given his distinguished career, I have no doubt that the House will hear a lot more from him.

The topic of today’s debate is how the UK Government propose to meet millennium development goal 5, relating to maternal death, maternal health and maternal morbidity. It is fortuitous that the Government published at the end of December 2010 their framework, Choices for Women: Planned Pregnancies, Safe Births and Healthy Newborns, for improving maternal health in the developing world. I congratulate them on producing that document, which sets out clearly the vision of the UK Government and their ambition to improve maternal health globally. It sets clear goals in each of the areas mentioned for the UK Government to meet by 2015. It is a little less clear about how this will be done, but I have no doubt that we will explore that today.

An article appeared in Delhi’s Hindustan Times on 29 August 2010, the day before the start of the first global meeting on maternal health, organised by the Bill Gates Foundation and the Indian Ministry of Health, which exemplified the problem in relation to maternal deaths. The headline was:

“She gave birth, died. Delhi walked by”.

It was the story of a destitute woman who died having given birth on a pavement on a busy street in central Delhi as thousands walked by.

In sub-Saharan Africa and south Asia, women die in childbirth, not of disease or epidemics but of conditions that are easily treatable: prolonged labour, haemorrhage, high blood pressure, infection and unsafe abortions. There is a lack of skilled attendance at births and a lack of access to emergency obstetric care.

The commitment made by world leaders in 1990 to reduce by 75 per cent by 2015 the 570,000 maternal deaths that occurred annually at the time—millennium goal 5—is the most off-track millennium development goal. While there was estimated to be some reduction to 350,000 yearly deaths by 2008, unless efforts are accelerated, the goal of reducing deaths by 75 per cent by 2015 will not be met.

In September 2010, an international alliance that included the United Kingdom was launched at the UN General Assembly. The UK’s leadership is well recognised globally, as alluded to by Melinda Gates in her New Year blog.

The causes of death remain the same: lack of skilled attendance at births, poor access to emergency obstetric care and health system failure. The Government’s framework states that it will address all these issues. It commits the UK, working in high-risk countries in sub-Saharan Africa, to reduce annual deaths by 50,000 by 2015. On the basis of what evidence are the Government confident that they can meet this goal? I hope that the Government will support other African countries, too, such as Tanzania, where there is a will on the part of local and national government, professional organisations and the population to improve maternal health, with some good examples of strong health systems. The UK can and must provide the co-ordination and leadership required and draw on the experience of professional organisations and individuals in the United Kingdom, who will happily contribute to the national efforts.

For the next few minutes, I should like to address obstetric fistula, a subject about which I have spoken previously—I make no apology for doing so again. At long last, after nearly six years of campaigning by a small group of people, obstetric fistula, from which an estimated 3.5 million women suffer worldwide, has come to the notice of the world’s politicians. I, for one, was very pleased that, following the adoption of a resolution by the UN General Assembly, the Secretary-General of the UN, Ban Ki-Moon, is calling for at least $750 million to treat the 3.5 million women who suffer from obstetric fistula. Of course, that is not possible, but I hope that the problem will at least get greater attention. As Ban Ki-Moon said, obstetric fistula is one of the most devastating consequences of neglect during childbirth.

Like maternal mortality, obstetric fistula is almost entirely preventable with skilled care during labour and access to emergency obstetric care. Obstructed labour, a major cause of maternal death, is also the main reason for a mother ending up with a fistula and, in most cases, a stillborn baby. She is left incontinent in relation to urine and she smells. She is made to live in social isolation. To the 3.5 million women with the condition, an estimated 50,000 to 100,000 new cases are added each year. Cost-effective, sustainable strategies, albeit on a small scale, have been instituted by a few dedicated groups.

I am privileged to be involved with one such group, co-ordinated by the International Federation of Gynecology and Obstetrics and the Royal College of Obstetricians and Gynaecologists in London. Over the past four years, it has established training centres for doctors and nurses and is in the process of treating 2,000 women with obstetric fistula. It has trained 32 doctors and nearly 50 nurses in Tanzania alone at a cost of approximately $300 for a woman treated and cured. That is not much. The UK’s framework for maternal health recognises that there is a problem that needs to be addressed. Beyond that, there does not appear to be any commitment. I hope that the call by Ban Ki-Moon will now energise DfID into some action.

The UK can provide a global lead in shaping the strategy to help to tackle the problem. We have a cadre of experienced surgeons in the UK. We have produced competency-based training manuals that are accepted globally for the training of doctors and nurses. We have the experience of running successful programmes. The UK can lead and co-ordinate with other partners. I hope that the Government will commit to some action. I know that the professional organisations stand ready to help. I am hoping for a positive response from the Minister. The publication of the framework demonstrates the Government’s recognition of the problem relating to MDG 5. I hope that resources to meet the goals will now follow.

My Lords, I declare an interest as chairman of the Commonwealth Press Union Media Trust. I start by congratulating the noble Lord on securing this debate on such a tragic issue.

As we have heard, 555,000 women in the developing world die each year from complications during pregnancy or childbirth. The most awful aspect is that so many deaths are avoidable because they are caused by a simple lack of awareness about basic primary healthcare and cleanliness. Information and communication are therefore vital in tackling the problem. This is an area where a free media with well trained professional health journalists must play a key role.

The evidence is strong. In countries that lack a vibrant press with specialist health reporters, maternal morbidity rates are most acute. Where the media operate effectively, the problem can be tackled head on. A recent report from the Open Society Institute showed how mass media campaigns in the area of HIV promote the adoption of prevention of mother-to-child transmission services, which are a key part of maternal health. In Rwanda, to take a concrete example, a mass media education programme has helped to reduce the maternal mortality rate from 750 per 100,000 live births in 2005 to 383 in 2009, so public information helps. A key priority for us should therefore be to foster programmes where skilled health professionals can work with specialist journalists to develop locally generated educational campaigns that can reach out to all members of the population.

One other area where a free media have a key role to play is in ensuring that there is transparency about what individual Governments are actually spending on maternal health issues. Last year, the International Budget Project conducted a survey to find out what 80 Governments were spending on issues relating to international goals, some relating to maternal mortality. Ten African countries with the highest maternal mortality rates did not bother to respond, while many others asserted that there was no central information on issues such as spending on life-saving drugs. To work out what needs to be done, as the IBP pointed out, we need to know what is already being done, which is far from clear.

The task of communicating information and of holding Governments to account requires a well trained and free media if we are to make further progress in dealing with the cruel scourge of maternal morbidity.

My Lords, I declare an interest as Emeritus Professor of Fertility Studies at Imperial College and Professor of Science and Society. Also, I was a scientific adviser to the WHO on its reproductive programme in the 1970s and an adviser to the International Planned Parenthood Federation during that decade.

I remember approaching, while I was on that mission, a Bangladeshi farmer who had five sons. He said, “Look, I am rich in my poor community because I have five sons who will look after me in my old age”. That is one of the key problems. Some 15 years ago in this Chamber, the noble Baroness, Lady Chalker, pointed out that contraception was not ultimately what “controlled” populations. Quite clearly, what is needed is better infrastructure and education, better status of women and better women’s health.

That is why I am somewhat critical of the aims that I understand are part of the Government’s, which are to improve contraception and safe abortion. While those are worthy causes, they will not deal with the basic problem of the massive incidence of maternal mortality, particularly in places such as Nigeria, Ethiopia, Congo and India, where 50 per cent of these deaths, with the other three countries that are cited by Margaret Hogan in her excellent paper in the Lancet, are recorded.

One has to accept that almost certainly the original half million is an underestimate. A 1.5 per cent decrease per annum will clearly not meet the targets that are needed. There is a serious problem, particularly as in many cases the number of maternal deaths—those from ectopic pregnancy, for example, which is largely silent and hardly ever diagnosed in the third world—must be underestimated. The same applies to abortion. Even where safe abortions are possible, it is difficult in many cases for women in these poor countries to seek them because of the social pressures on them. There is a huge amount of work still to be done.

My Lords, user fees for healthcare can be a key barrier to achieving MDG 5 in developing countries. While contributing on average only 5 per cent to healthcare costs, they leave too many women with no choice but to give birth at home with no qualified medical assistance. Sierra Leone removed user fees in April 2010 with DfID and other donor support. The number of women giving birth in hospital doubled in the first month and continues to rise.

In the first month alone, antenatal clinics in Freetown saw seven times more women than they ever had before. According to Oxfam, since removing fees Uganda has seen an 84 per cent increase in attendance, while Burundi has seen a 60 per cent increase. In Niger, consultations for under-fives have quadrupled and for mothers have doubled. In the light of that compelling evidence, will the Minister confirm the Government’s continued commitment to maternal health multilateral aid through, for example, the UK’s support for the Global Fund?

In fragile states such as DRC, achieving MDG 5, as with any of the other development goals, requires the international community to consider more thoroughly and widely the political dimensions of DRC’s poverty. In that context, will the Minister tell us what steps the Government will take to support the development of parliamentary accountability in the DRC?

More generally, what measures are the Government taking to ensure that improved government accountability is featured alongside MDG programmes? A key issue associated with maternal health and MDG 5 is sexual gender-based violence. DRC is recognised as one of the most dangerous countries in the world in which to be a woman, yet in its 2011 national budget just 0.1 per cent was allocated to the Ministry of Justice, making a mockery of claims to show zero tolerance of rape and SGBV. What representations have the Government made to the Congolese over the inadequacy of DRC’s budget for its Ministry of Justice, particularly in this regard?

My Lords, as I rise to make my maiden speech, I am conscious that it is customary to thank the staff of the House for all their help, as I begin like a new boy at school to find my way around. Although everyone promised that this would be so, it is an absolute delight to find just how true it is. My thanks are absolutely the reverse of perfunctory.

My thanks go, too, to my sponsors, the noble Lord, Lord Griffiths of Fforestfach, and the noble Baroness, Lady Warwick of Undercliffe. Both are close friends of mine. The fact that one sits on these Benches and the other on the Benches opposite matters to me not a jot. I am normally happy to follow the conventions of the House, but on this occasion at least I can say that both, and indeed others on various Benches of this House, are my noble friends.

I thank the noble Lord, Lord Patel, for introducing today’s debate on maternal health in the context of the millennium development goals. I am keen to contribute, as I have taken on the role of Minister of State for Trade and Investment. I believe passionately that there is a vital connecting thread between trade and investment and the millennium development goals. My own perspective is formed not only by having worked in international management consulting, followed by an extensive career in international banking, but by having begun my working life in DfID, or rather its predecessor, the Overseas Development Administration, as it was then known.

I make four brief points. First, the various millennium development goals are of course intrinsically linked. The most obvious example of that, and directly relevant to today’s debate, is the connection between progress on gender equality, which is goal 3, improved maternal health, which is goal 5, and reduced child mortality, which is goal 4. The evidence is clear: children in poor communities are 10 times more likely to die before the age of five if the mother has died. The link, too, with disease—goal 6—is clear. HIV is the leading cause of death in women of reproductive age in sub-Saharan Africa and malaria alone is responsible for 20 per cent of child mortality there.

Secondly, progress in meeting the goals is mixed. There have been some important gains, with good progress in eradicating extreme poverty—goal 1. Some countries have made astonishing progress. China, for example, has lifted literally hundreds of millions of people out of poverty in recent years. Yet the mountain is still high and there is a long way to climb. Demographic patterns have meant that absolute numbers have declined much less sharply than the ratios of poverty, and the absolute numbers remain high by any standard. More broadly, across a range of targets, there is a long way to go. We have heard from a number of noble Lords about the difficulties in respect of maternal health.

Thirdly, specific interventions can be powerfully effective. Well targeted ODA and NGO-supported programmes in areas such as fistula can make a real difference to many people’s lives and indirectly to even more lives through the effect on children.

Fourthly, none of this will ever add up to sustainable, comprehensive well-being without progress—real progress—on goal 8. On the face of it, this is the woolliest goal of all. It seems like a ragbag of ideas bundled together as the last goal but it includes the all-important challenge to further develop,

“an open, rules-based, predictable, non-discriminatory trading and financial system”.

This is critical to everything else that we do. It is certainly not sufficient but it is absolutely necessary. Historians will note the importance of the words of the G20 communiqué from London in April 2009, where the heads of the Governments of 80 per cent of the world’s economy said that we start from the belief that,

“the only sure foundation for sustainable globalisation and rising prosperity for all is an open world economy based on market principles, effective regulation and strong global institutions”.

I see this as the basis for real hope. It is easy to be cynical, but that would be wrong. There is plenty to do. Progress is mixed and there are many lessons to be learnt from the global financial and economic crisis. One lesson not to learn, if we really care about the aspirations that infuse the development goals in general and goal 5 in particular, is the notion of some alternative to a central role for open, market-based engagement—properly supervised—as the main engine of the economic and social development that is essential if we are to banish today’s unacceptable levels of child and maternal mortality for good.

Trade and investment is an area of policy focus for the UK that is critical not only to the UK’s own ability to deliver sustainable growth for its citizens, which it certainly is, but also to the wider goal of a prosperous, open, growing world economy that is sustainable and inclusive. This aspiration is both our wider responsibility and in our wider interest.

My Lords, I thank the noble Lord, Lord Green, for his wise and insightful speech. He comes with a distinguished career and immediately gave a big framework and a focus to help us understand this debate and where it is going. I thank him and look forward to his contributions in future.

I thank the noble Lord, Lord Patel, for drawing attention to this important issue, and I make one simple point. We have heard and will hear a range of insights into how this issue can be tackled. Many of these insights and much of the documentation are quite properly about scientific, medical and organisational strategies to try and help people in enormous need facing enormous challenges. You will not be surprised that I want to remind the House that birth and death are for most people essentially spiritual issues. There is little mention in the aspirations and the documentation about the element of faith and spirituality.

I am pleased that the Government are bold in their big society agenda in drawing attention to the role of faith in society, education, well-being and values. I hope we can think seriously about the role of faith as we try to pursue these goals. I cite two small examples of this. First, the Mothers’ Union has 3.6 million members and operates in 81 countries at the grassroots level. Secondly, if we want to confront how we pursue and deliver these goals with the people, through the people, there is a faith organisation that is right in the middle of the challenge. In the Congo, 60 per cent of healthcare is delivered by Christian churches. Can the Minister comment on the place of faith and working with faith communities in taking seriously these goals and pursuing them effectively?

My Lords, I congratulate the noble Lord, Lord Patel, on securing this debate, and the present Government on the leadership they showed early on by promoting women’s health and in particular in improving the provision of contraception and safe abortion in developing countries.

The previous Government were equally enthusiastic, but sadly an estimated 350,000 women still die in childbirth and millions suffer permanent damage to their health as a consequence. Imagine a jumbo jet full of passengers crashing every day of the year. The press would go mad. Rupert Murdoch might notice and take action. Yet the same number dying each year for lack of obstetric care raises not a whimper. What a pity men do not have the babies—action would have been taken decades ago.

The coalition published the framework for action before Christmas and I congratulate them. How much money will be allocated and how will the Department for International Development monitor the results? We need to ensure real progress this time because the success of developing countries depends on the health and welfare of its women. There is no question of that.

The rest of my speech can be read in the report produced by the All-Party Parliamentary Group on Population, Development and Reproductive Health, asking whether some women in developing countries might be Better off Dead? It is on our website, so please read it.

My Lords, I am grateful to my noble friend for following up the short debate of the noble Lord, Lord Crisp, which I missed. The 2015 deadline for the health MDGs is looming nearer. I have seen the recommendations of the UN taskforce implementing a $40 billion global strategy for women and children’s health. They are formidable but I was struck by one passage:

“The chasm between what we know and what we do, between our ability to end poverty, despair, and destruction and our timid, often contradictory efforts to do so lies at the heart of the problem … the challenge posed by the MDGs is deeply and fundamentally political. It is about access to and distribution of power and resources”.

It is important that health practitioners, when coming into contact with global health, take note of these words because they take us to the heart of the community involved.

In southern Sudan, for example, on the eve of its independence, a lot of money has been earmarked for health through the Government and the multi-donor trust fund but little has been spent effectively. There have been delays in implementation, logjams in drug procurement, problems in paying health workers and transferring funds into services—every kind of obstacle you expect in a poor country, only worse. The most experienced NGOs there are frustrated. No one is giving up. It will just take a long time and many mothers and children will die waiting. This is the hard lesson that we have to pass on to dedicated teams who are rightly desperate to help these countries meet their millennium goals.

The latest UN development report reminds us that global healthcare need not be expensive but it will thrive in a more democratic and politically friendly environment. It is sometimes assumed that the ill health of the poor stems from their own ignorance and that we have to fill an acute knowledge gap that exists between rich and poor. However, my experience is that the very poor, given half a chance, are the best architects of their own development, whereas outsiders are not.

My Lords, I care about international development and the achievement of millennium development goal 5. When I attended the sixth Asia-Europe Parliamentary Partnership meeting in Brussels recently, I successfully tabled an amendment to the final declaration calling for greater efforts to improve maternal health and to reduce maternal mortality.

I feel that it is pertinent to draw attention to the growing adolescent birth rate. Poverty continues to be a factor in perpetuating that worrying trend, but education also plays a significant role. Research suggests that adolescents who have not had access to any type of formal education are four times more likely to fall pregnant than their peers who have completed secondary school.

Improving maternal health is not only a moral obligation but financially prudent. It has been argued that at least 30 per cent of Asia’s economic growth was due to sustainable improvements in reproductive health. The United Nations Global Strategy for Women’s and Children’s Health suggests that maternal health problems result in losses to productivity of up to $15 billion per annum.

I welcome the Government’s commitment to support the global fund in its work to combat the rise of HIV, tuberculosis and malaria in the world’s poorest nations. More than 1 million people with tuberculosis are also infected with the HIV virus. Tuberculosis is responsible for the deaths of more than a quarter of people with the HIV/AIDS virus. In 2008, tuberculosis was responsible for the deaths of more than 300,000 expectant mothers, especially in sub-Saharan Africa.

I am also in favour of the coalition Government’s plan to tackle malaria and to reduce maternal fatalities. Malaria kills a child in Africa every 45 seconds. The plans will also ensure that, over the next five years, a minimum of 10 million couples will gain access to education on family planning. Infants and pregnant women are the main victims of malaria-related deaths.

I believe that we have a duty to ensure that lasting progress is made to fulfil millennium development goal 5 by 2015. As a leading nation in the global arena, we must ensure that goal 5—part of the challenging programme that was agreed 15 years ago—results in success.

I thank the noble Lord, Lord Patel, for inspiring this debate. I pay my warmest tribute to the noble Lord, Lord Green of Hurstpierpoint, for his thought-provoking and powerful maiden speech.

The context of this millennium development goal is that maternal mortality initiatives should be incorporated within a preventive healthcare framework. On structure, an effective first step to reduce the incidence of maternal mortality would be to create integrated mother-child healthcare—MCH—units within primary healthcare centres to secure an increase in the accessibility and availability of MCH care.

To encourage attendance, the availability of MCH units should be widely advertised among the catchment area population through, for example, health education outreach programmes such as the women health volunteer programme.

Encouraging good health habits is essential. MCH units should be physically designed in a way that takes account of the patient’s needs for privacy and dignity. Ideally, such units should also have the capacity to accommodate other young members of the family while mother has her consultation. Emphasis should be placed on encouraging patients to return, to attend regularly when advised to do so, to encourage others to attend and to inculcate good health habits within the community.

Traditional birth attendants should be professionally trained. That must be a priority, with a view to increasing the number of births attended by skilled and professionally qualified birth attendants.

Local staff should be used to overcome sociocultural barriers. Programmes that are implemented by local health professionals are much more likely to be able effectively to influence situations in which a strict interpretation of traditional social practices inhibits the timely treatment of women in urgent need of medical assistance. An example of that might be the refusal to allow female relatives to be treated by male doctors.

I chair the AMAR International Charitable Foundation, which provides more than 1 million Iraqi people a year with primary healthcare. Our maternal mortality conference operates in the Iraqi marshlands, where local AMAR doctors who have presented case studies of avoidable maternal deaths have enabled tribal leaders to pledge actively to take responsibility for reducing the number of such cases.

If we follow up such steps with referral procedures, follow-up procedures, improved patient records and maternal mortality data as well as education for mothers, we will find that infant and child mortality, as well as maternal mortality, is comprehensively improved.

My Lords, in my brief contribution, I will focus particularly on MDG 5b, which mainly covers the contribution of reproductive health and family planning to the subject of this debate.

As we have heard, the Department for International Development moved the issue forward significantly with its many announcements on 31 December last year, although the specific allocation of money is still to be decided in the spending review that is to come shortly. The headline and bullet points given in a useful article in the Guardian on that day were very encouraging. The article states:

“The coalition government will put contraception and safe abortion at the heart of its efforts to help save women's lives in poor countries … Safe abortion and contraception take centre stage in the framework on maternal health”.

In this context, no one is referring to abortion as a method of family planning. The reference is to safe abortion, as opposed to unsafe abortion that all too often leads to a fatal outcome. The article goes on:

“Family planning to help avoid unwanted pregnancy is considered good value for money – it was estimated in 2008 that modern contraceptive methods cost … £5 … per woman per year”.

It is to be hoped that the forthcoming spending review will also increase the amount that is spent bilaterally directly on family planning, which has recently not increased as much as other, similar aid.

The article also tells us that,

“there will be ‘significant’ spending on reproductive health, with the aim of enabling … women ‘to choose whether, when and how many children to have’”.

I hope that that momentum will also carry over to affect how we contribute funds for development through the EU so that those can be radically reviewed and fed into the process of review within the EU that is going on this year.

My Lords, one of the best weapons in the Government’s armoury that could help to meet the entirely laudable aims of millennium development goal 5 would be to press for better governance, on the way to the holy grail of good governance, in the countries that we seek to help in this respect. Outright corruption and bribery—with their twin and just as damaging siblings of weak regulation and indolent service delivery, often using donor aid—hit healthcare hard.

Look at sub-Saharan Africa. The World Bank’s African Development Indicators 2010 shines a revealing spotlight on the severe effects that follow from what it delicately terms “quiet corruption”. The report cites examples such as that about half the drugs that are sold in Nigerian drugs stores are counterfeit. The same report equally politely refers to “provider deviations” from the norms of expected behaviours of some doctors, nurses and other front-line providers, with the petty palm greasing, attendant absenteeism and low levels of effort. Those are very uncomfortable but very true facts, which are well documented.

Above all, we must face up to the fact that private donor aid, as well as public spending from countries such as the United Kingdom, will in the end comprehensively reduce mortality only when governance is better and transparency about performance and behaviour is vastly improved. We need that if we are to bring help in an area where more than half of all births occur without trained personnel being present, despite the excellent efforts of UK-based charities such as CAFOD. CAFOD’s innovative birth attendants training schemes in the selfsame Nigeria help to lead the way, as do the initiatives of the other faith groups that were referred to by the right reverend Prelate the Bishop of Derby in his very telling remarks.

My Lords, I congratulate the noble Lord, Lord Patel, on securing this important debate and the noble Lord, Lord Green, on his very interesting maiden speech.

In 2009, I joined Commonwealth Parliamentary Association delegations to Sierra Leone and Cameroon. I am a patron of the Kambia appeal, in my former constituency of Cheltenham, which supports healthcare in the Kambia region of north-east Sierra Leone. Both CPA delegations attended presentations about gender issues, covering the huge birth rate, the need for education, pre and postnatal care, contraception, violence towards women and the tragedy of so many deaths caused by illegal abortions.

I want to tell noble Lords particularly about the session in Cameroon, which was also attended by Members of the Cameroon parliament. One outspoken chief asked why gender issues always meant women’s issues. He said that it was the role of men to be head of the family and to lead the way, and he dismissed many of the problems and said female genital mutilation—FGM—was exactly the same as circumcision in boys. This shocked us. It produced an explosive response from our delegation leader, the former MP Joan Ryan. She told him that he was talking gibberish, that FGM was an appallingly disfiguring practice that should be outlawed and that two children were enough for anyone if Cameroon wanted to progress by enabling women to play a full economic part in their country’s development, instead of leading lives of continuous breeding from an early age. She finished by telling the chief: “Girls are just as intelligent as boys. Women are equal to men, and if you don’t like it we may just have to dominate you”. How she is missed in another place.

We must help men in developing countries to understand their responsibilities in helping to achieve MDG 5. Without that breakthrough, I fear that we will continue to see women dying before childbirth, in childbirth and after childbirth in numbers that are all too horrible to imagine.

My Lords, I congratulate my noble friend Lord Patel on raising this issue and sparking this excellent debate. I also congratulate this and the previous Government on giving the priority that they have to this issue. The question is: why is more not happening faster? There are improvements but it is not fast enough. Three things come together here.

First, on the clinical issue, we have heard from clinicians in the Chamber and elsewhere that, clinically, people know what to do. Obviously, you can do it better but two other issues go alongside the need for good clinical leadership. Secondly, it is particularly about the resources of health workers and having more appropriately trained health workers. The third issue, which is the hardest to tackle, is the one that the noble Lord, Lord Jones, has just referred to: the matter of social issues. There are issues of women’s inequality, of women not being able to leave the house without a man’s permission, of women not having money of their own, of whether women are allowed to manage the finances in a family and of whether it is acceptable for young, underdeveloped women to marry and to bear children.

Those are all issues for the whole society, particularly for men, and it is interesting to see examples of countries such as Zambia where people actively work with the leaders, whether they are the spiritual or the traditional leaders of the country, to change social attitudes. It is my belief that you need these three things to work together in a country: clinical leadership, political leadership that will in part release the resources and civil society leadership, which embraces media and other aspects that have been referred to. What are the Government doing to make sure that those three issues are addressed together? I believe that doing so is what will make a difference.

Perhaps I might add one quick footnote on an issue that my noble friend Lord Patel raised in his excellent speech. There are many people in the UK willing and able to help provide support, from his own college and elsewhere. Can the Minister tell us what is being done to enable people to use their skill and good will for the benefit of dealing with this problem?

My Lords, I, too, congratulate my noble friend on introducing this very important subject. I will focus on a country currently in the news and in much need of help, Southern Sudan, where fulfilments of MDGs seem a distant dream. When I was in Southern Sudan some months ago, these grim statistics highlighted the situation. One in seven pregnant women dies in pregnancy or childbirth. Immunisation is available for only 17 per cent of the population, leaving 83 per cent vulnerable to avoidable diseases such as polio, measles, diphtheria and tetanus. A girl is more likely to die in pregnancy than to have access to secondary education. We were told that there are only 10 fully qualified midwives for the whole of Southern Sudan. In many rural areas around towns such as Yei, roads are so bad that access to hospitals may be virtually impossible. A woman with obstructed labour may have to endure over two hours on the back of a bicycle to reach a hospital; many die en route. The destruction of educational institutions during the war has left a dearth of young people with educational qualifications to apply for professional training as nurses and midwives.

Those statistics will be even worse now, with massive numbers of returnees fleeing from the north in fear of reprisals following the referendum. They are now living as displaced people in dire conditions, with no adequate facilities for care and no homes to return to. Following the referendum, there will be an urgent need to address these problems if the existing humanitarian crisis is not to escalate even further, with a risk of undermining political stability. DfID has made significant funding available but in areas where my NGO, HART, is working—Northern Bahr-El-Ghazal, Equatoria and the Nuba mountains—we see little evidence of DfID’s funding. I therefore ask the Minister for reassurance that DfID’s resources are being used effectively to address these priorities of maternal mortality in these critical days in Southern Sudan.

My Lords, I, too, add my thanks to the noble Lord, Lord Patel, for the initiative that he has taken this evening and for his long and fine commitment to the issues that we are discussing. I also thank the noble Lord, Lord Green, for his contribution and I certainly agree with the points that he made, particularly on trade and development and on MDG 8. I wish the noble Lord well as a Member of this House.

The fundamental reality should of course be that no woman should die giving life. Pregnancy, as I can confirm, is a cause for celebration and surely not for despair, disability or death. I met a woman once who was about to go into labour; before doing that, she went to say goodbye to her children. That is the kind of story which really resonates and tells us what this debate is all about. We hear many fine words on maternal health but I regret that, after following this issue for many years, I do not actually see any real global fulfilment of the political or financial commitments that we have heard being made.

To answer the questions raised by the subject of tonight’s debate, should we not point, as some noble Lords have, to the low status accorded to women and, indeed, to the low value placed upon saving women’s lives—lives that have been characterised by vulnerability, exclusion and poverty? Is not this debate about women’s rights to a fair distribution of power and resources? Indeed, we would serve the objectives of meeting all the MDGs if we were to focus on achieving equity, tolerance and shared responsibility, which means recognising women’s rights. Time is short for MDG 5. It has become a popular cause but other issues are coming up. For instance, in 2011 the World Health Organisation is prioritising communicable diseases for the entire year.

Other Members of the House have outlined the problems that women encounter in terms of medication, birth attendants and other vital issues. Many women want to plan their families, yet family planning fails to meet the pace of the demands which women are making. Again, the reality is that women do not have control over their reproductive rights because they just do not have access to those rights. Finally, sadly, we should acknowledge that progress on MDG 5 is, I fear, too slow to hit the target on time.

My Lords, I thank the noble Lord, Lord Patel, for securing this important and very timely debate. From the level of interest, the number of speakers and the wit, knowledge and wisdom of your Lordships’ House, today yet again highlights the great strength of your Lordships’ knowledge. I know that time will not permit me to answer all questions today, so I ask noble Lords to allow me to write to them if I do not answer theirs. I join all noble Lords in congratulating my noble friend Lord Green of Hurstpierpoint on his most excellent maiden speech. I am sure that it was just a tiny nugget of the superb contributions that my noble friend will bring to your Lordships’ House, as well as carrying out his ministerial duties as our trade Minister, a field in which he already has enormous recognition.

We all know that millennium development goal 5, to improve maternal health, is one of the most off-track MDGs. Each year, more than a third of a million women and girls die in pregnancy and childbirth and some 50 million give birth without skilled care. There is not much with which I can disagree in what noble Lords have said today—there is so much to be done. But I assure all noble Lords that this Government are determined to do their best to meet all the targets that we are setting ourselves.

For every woman who dies, up to 30 more suffer a debilitating illness or permanent disability, as the noble Lord, Lord Patel, has highlighted, which is often accompanied by stigma and discrimination. I congratulate the noble Lord on the work that he and his organisation are doing. I am sure that the department would be pleased to hear much more about it.

On the question of how we measure what we are doing, the framework sets out how we will clearly measure our outputs, our programmes and of course our end results. Most deaths in pregnancy and childbirth in developing countries are entirely avoidable. Globally meeting the unmet need for family planning alone could avoid around one-third of maternal deaths and one-fifth of newborn deaths. Yet 215 million women who want to delay or avoid a pregnancy are not using an effective method of family planning. Each year there are 75 million unintended pregnancies, of which 44 million end in abortion. In 2008, an estimated 22 million unsafe abortions took place, resulting in around 70,000 maternal deaths.

I agree that conflict can seriously aggravate the challenges of tackling maternal mortality and morbidity, such as the high levels of sexual violence, as the noble Lord, Lord Chidgey, pointed out, which is why we support the UN Security Council resolution and its sequels to demonstrate the international commitment to improving the lives of women affected by conflict. The UK Government strongly support those efforts, as we have encapsulated in a new national action plan on women, peace and security, which was launched in November 2010. The Government are reorienting the development programme to put women at its heart, empowering women to make their own choices for their health and the health and well-being of their families.

The benefits of investing in women’s health are far reaching. Improved reproductive health can improve the status of women, enabling them to live free from maternal illness and to make choices about their bodies and lives. Improving women’s health during pregnancy and childbirth saves not just their lives but those of their children. Meeting the demand for family planning services, together with wider investments in education and women’s empowerment, will reduce unwanted fertility and slow population growth.

All those improvements would all have much wider benefits for families, societies and economies, as my noble friend Lord Green has pointed out. The millennium development goals, for example, will help eradicate household poverty, and will have a national benefit when mothers and babies are healthy and when high fertility rates fall.

The case for investing is strong. Evidence tells us that investing in reproductive, maternal and newborn health is excellent value for money. Family planning is one of development’s best buys in global health due to its low cost and far-reaching benefits. Responding to the unmet need for family planning will be one of the defining international development priorities of this Government.

The debate, of course, is very timely. On 31 December 2010 the Government’s new Framework for Results for improving maternal, reproductive and newborn health was published. Called Choices for Women: Planned Pregnancies, Safe Births and Healthy Newborns, it sets out how the UK will double its efforts on women’s and children’s health over the coming years.

The Government’s two main aims are to prevent unintended pregnancies by enabling women and adolescent girls to choose whether, when and how they have children, and to ensure that pregnancy and childbirth are safe for mothers and babies. The Government will double the UK’s efforts on women’s and children’s health to save the lives of at least 50,000 women during pregnancy and childbirth and 250,000 newborn babies by 2015; to enable at least 10 million more women to use modern methods of family planning by 2015, including up to 1 million young women; to prevent more than 5 million unintended pregnancies; and to support at least 2 million safe deliveries, ensuring long-lasting improvements in quality maternal health services, particularly for the poorest 40 per cent. This doubling of effort is backed by the doubling of resources for women and children’s health, as announced by the Deputy Prime Minister at the UN summit in 2010.

The noble Baroness, Lady Kinnock, asked about funds. This Government have pledged to enshrine in law 0.7 per cent of GNI by 2013. This is the UK’s contribution to an international global push to improve maternal health, supporting the United Nations Secretary-General’s global strategy for women’s and children’s health, which was agreed in September. Our new Framework for Results outlines a comprehensive approach to improve maternal health from before and during pregnancy, through delivery to the very important first few hours and weeks after birth, known as the continuum of care. It places a particular emphasis on reaching those who often find it the hardest to access services.

The framework has four pillars for action: to empower women and girls, to remove barriers, to expand the supply of quality services and, most importantly, to enhance accountability. We will implement these pillars across DfID’s country programmes. We will focus where the need is great and where the UK has a comparative advantage. We will improve the effectiveness of the global response, including that from international institutions and civil society. We will harness the UK’s expertise to improve maternal health in the developing world. To ensure that commitments are made a reality, though, we need good intentions, action at scale and clear, demonstrable outcomes that are tracked and monitored. The core results in the framework will be the basis by which we and others will monitor our performance in achieving our aims across our programmes.

My noble friend Lord Black is right: better transparency and accountability, of which a free press is a part, will contribute to improved service of delivery. The Framework for Results recognises the role that the media can play in enhancing accountability between women and wider civil society, service providers and governments.

The noble Lord, Lord Patel, asked about the framework and how it would be done. It sets out how we are going to achieve overall results, and a series of current reviews will be completed on all our DfID programmes, which we will then develop into operational plans over the coming months. We want to ensure that programmes are targeted towards those who will have the best possible opportunity to have improvement in their lives.

I know that this debate has stirred a lot of emotion among noble Lords, and with so many speakers it would be difficult to respond to each individual question. I hope that noble Lords will allow me to write to them in depth.

We have a unique opportunity. The United Kingdom wants to be at the heart of making progress in ensuring that MDG 5 is achieved by 2015. The UK will play its part, but noble Lords in this Chamber have so much expertise and wisdom that they are duty bound to ensure that they also help us in developing our programmes. We are always open to discussion, and we hope that noble Lords will take every opportunity to discuss the programmes with us.

Once again, I thank all noble Lords for their contributions. I thank my noble friend Lord Green for his immensely important contribution, and I look forward to hearing more from him.

Sitting suspended.