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Female Mortality (Africa)

Volume 499: debated on Wednesday 11 November 2009

Thank you very much indeed, Mr. Benton. This is the last debate of the day, and I thank you in advance for your chairmanship.

I am delighted to have an opportunity this evening to discuss a problem that I believe the Minister, his Department and the Government have taken seriously and on which we have a lot in common. I want to try to draw attention not only to the problems, but to some of the low-cost solutions that we can perhaps bring to bear.

In the UK, no woman in the advanced stages of labour would be expected to walk 30 km to receive medical treatment; that would be unacceptable. No woman in the UK would be allowed to die for the want of such basic medical treatment as a blood transfusion or a simple antibiotic to ward off infection. In the UK, fewer than 13 women die in childbirth for every 100,000 live births, but in Mozambique one woman dies in childbirth for every 100 live births. That is unacceptable, and to stand by and allow it to happen is simply not acceptable.

Every year around the world, 80 million women face an unwanted or unplanned pregnancy; 20 million women risk an unsafe abortion rather than carry their pregnancy to full term, and 68,000 women die as a result of botched abortions. Every year around the world, 50 million women suffer from a serious pregnancy-related illness and 4 million women are disabled as a result of pregnancy or childbirth. One woman dies every minute from problems related to pregnancy or childbirth. That is not to mention the many millions of women every year who are permanently disabled, left unable to walk or ostracised by their communities because of severe incontinence. The tragedy has reached such a scale that, in their recent report, Baroness Tonge and the all-party group on population, development and reproductive health questioned whether a significant number of the women affected by those problems would be better off dead. That is an incredibly sad thing to say.

However, the real tragedy is that 80 per cent. of these deaths result from one of the five well understood and relatively common obstetric complications that can be readily treated with existing and inexpensive medical or surgical interventions. They are: bleeding; infection; complications of abortion; high blood pressure associated with pregnancy, and prolonged or obstructed labour. All of those problems would be treated with standard simple medical solutions here in the UK.

What is the Department for International Development doing to help to resolve those problems? I put on record the fact that DFID should be congratulated on, and we should be proud of, the work that it has done so far. Its 2004 document, “Reducing maternal deaths: Evidence and action”, is an excellent piece of work. It set international standards, establishing a clear strategy for tackling the tragedy and for meeting millennium development goal 5, which is:

“reducing mortality by three quarters between 1990 and 2015”.

I understand that that strategy is being updated to take into account the fact that millennium development goal 5 has been amended to include an additional target to be achieved by 2015: universal access to reproductive health care. I know also that DFID has been working closely with the Norwegian Government to produce an evidence paper that will set out the strategies that have been proven to work in improving maternal mortality rates on the ground. All of that work should be applauded.

A great deal more could still be done, however. At the current rate of progress, we will never meet millennium development goal 5—it will be beyond us. Maternal mortality in developing countries has barely decreased in the past decade, despite the efforts that our Government and others have made. In parts of Africa, maternal mortality and morbidity rates have increased. Some have argued that the targets are too ambitious, but they are not. We must question whether our response could be more effective; we need to heighten our work on the solutions rather than on the problems. There is evidence that it is possible dramatically to reduce maternal mortality rates relatively quickly. In three countries—in Egypt, Honduras and Yunnan in China—the maternal mortality rate has already been successfully reduced to about 100 deaths per 100,000. Honduras has reduced its rate by nearly 50 per cent. in the past seven years. Such changes are achievable.

The failure to mobilise world efforts to reduce maternal deaths stands in sharp contrast to the successful efforts of past decades to reduce child mortality and recent global efforts to tackle HIV and AIDS, tuberculosis and, of course, malaria. The relative lack of investment in reducing maternal mortality is deeply worrying when compared with the investment in tackling health problems such as major communicable diseases.

Maternal health has not had a high profile internationally, and the international conferences of 1987 and 1997 have not led to sustained action on the scale that is needed. The reduction of maternal mortality should be defined as both a human rights issue and a health issue. Almost all such deaths are avoidable and are rooted in inequality of access to care, which is a sign of a denial of women’s rights. Maternal mortality rates reflect the greatest disparities between rich and poor and they are a good indicator of the extent to which a health system is rights-based. Indeed, DFID has gone so far as to say, in paragraph 63 of its 2004 report, “Reducing maternal deaths: Evidence and action”, that

“maternal mortality can be considered as the best single indicator of the effectiveness of a country’s health system.”

Hallelujah! That is absolutely right.

Sadly, in many countries women’s rights are consistently overlooked and ignored. In the UK, we do not consider women’s health care to be a secondary priority; for that reason alone, we should take the lead on this issue internationally and redouble our efforts. In addition to the moral and ethical arguments, there is an economic argument. The USA has said that maternal and newborn mortality accounts for costs in lost productivity of $15 billion a year across the world. The death of a mother is a sharp and unpredictable shock to the livelihood of any household and is likely to deepen poverty. Few poor households are secure enough to absorb the loss of their most economically and socially active member, and every year as many as 2 million children are orphaned by the death of their mother. If we want the millennium development goals to mean something, we need to stop that travesty and see what concrete steps we can take to bring change.

In 1994, Thaddeus and Maine described the three delays that contribute to maternal mortality: delay associated with the decision to seek care, delay in arriving at the point of care and delay in the provision of adequate care. In my constituency, one small social enterprise company, eRanger, is attempting to tackle each of those delays with practical and low-cost solutions. Looking at the problem differently will give us the greatest breakthroughs. The eRanger company produces low-cost motorcycle-side trailer combinations that offer three customised options: an ambulance, a mobile clinic for outreach work and a mobile education unit. It utilises a robust 200-cc motorcycle with a custom-built, padded sidecar in which a patient can lie down and be safely strapped in. In an emergency, a nurse or midwife can travel behind the driver—

Sitting suspended for a Division in the House.

On resuming—

As I was saying, the eRanger motorcycle, with its custom-built sidecar, can also take a doctor or nurse as a pillion passenger, if that level of support is needed.

The average cost of an eRanger ambulance is £4,000, which includes spares to allow smooth running for 12 to 18 months or 10,000 km. The vehicles are put together in South Africa; a local co-operative is used to build the cycles and sidecars. The price equates to about one sixth of the cost of a 4x4, and there is less opportunity for abuse by local workers. In other words, for every 4x4 operating as an emergency medical care vehicle in Africa, there could be six eRanger vehicles, reaching six times more women and potentially saving six times more lives.

The eRanger education unit is vital in teaching women about birth control, but the ambulance model has proved to be the most successful in combating female mortality. In August this year, UNICEF, recognising the very significant contribution that the eRanger ambulances made, signed a long-term agreement, for two years, to supply eRanger ambulances, mobile clinics and education units. So far, 22 ambulances have been delivered to Sierra Leone, and eRanger has an expected order for between 20 and 50 ambulances for Liberia. Since 2005, more than 400 eRangers have been deployed in Africa and Afghanistan. In 2004-05, DFID sponsored a pilot scheme in the Dowa district of Malawi using 21 bikes, and about 250 eRangers are now in operation in Malawi. The Minister of Health for Malawi plans to place a combination of eRangers in every single health centre in the country under community control. Largely as a result of eRanger presence and, indeed, the support of DFID, maternal mortality rates in Malawi have dropped by an incredible 60 per cent. since 2005.

Access to an eRanger motorcycle can ensure that a woman in labour gets to her “local” health centre. The drivers are on call using satellite mobile phones and can get to most women extremely quickly, which can almost entirely remove delay 2 in Thaddeus and Maine’s analysis. The motorbikes can also significantly contribute to the reduction of delay 1, associated with the decision to seek medical help. The education bikes can inform women of the medical treatment available to them, reassure them of its safety and remove the common perception that medical centres and hospitals are just places where people go to die. The fact that the journey is free, easy and safe also encourages many women to seek help rather than suffer in silence. Once at the medical centre, eRanger bikes can be a further help with delay 3. There are many reported cases in which blood transfusions or other supplies were needed at a medical centre, but there were simply not the resources to deliver them to the patient. The eRanger is an affordable way of solving the problem.

As demonstrated in Malawi and across Africa, the bikes can make a world of difference, so why are they not more widely used? What I seek today is a more active response from DFID. Despite DFID’s encouragement of eRanger’s work to date—I acknowledge that it has been supported—the organisation currently has no point of contact within DFID. It is difficult to understand where DFID is placing its effort in Africa, particularly in sub-Saharan Africa, without having a point of contact, yet that is something that could easily be achieved. The organisation has no interaction with DFID in the UK regarding planned or implemented projects that could benefit from using eRangers as part of a maternal mortality road map. The very thing that DFID says that it wants to do—I believe that it does want to do it—could be helped if there was some interface with what is a very small non-governmental organisation.

Unlike the agreement with UNICEF, there is no agreement with the Department to supply eRangers to DFID projects. It is extremely difficult to interface with organisations in Africa and Afghanistan unless one has a contact in DFID in those countries that will open doors. Although the Minister has given a pledge to supply those contacts, that arrangement does not appear to be in place at the moment. It seems that DFID will only interface with large, established NGOs, yet often it is organisations such as eRanger that can provide huge advances at a fraction of the cost.

In DFID’s strategy document, the Department states:

“Effective communications and transport are critical to success…New solutions to reduce barriers are needed.”

The eRanger organisation does exactly that. It has produced a low-cost solution to deliver the sorts of health care provision that we need. Clearly, eRanger is a solution that has been proven to reduce barriers, and I hope that the upcoming evidence paper will reflect that. It would be of great assistance if the Minister assured eRanger that it will have sight of the new updated paper as soon as it is published, and if he agreed to himself or his policy officials meeting myself and representatives of eRanger to discuss further engagement with DFID and how to combat the problem of maternal mortality internationally. In addition, will he commit to agreeing to supply eRangers on DFID projects, should the evidence paper find that that is a successful and economically viable intervention? If it does not, fair enough.

Finally, I place on record my thanks to the Minister and his officials for the impressive work that the Department has carried out in this area. My plea is for him to go further, to think outside the box, not to reject small NGOs and to make a real difference to women who currently suffer needless pain and death. As Dr. Kiptu, the medical officer in charge of Magunga health centre in Kenya, states:

“It is not just making things better in the hospital—it is saving lives every day. God bless you for that.”

Let me, in the usual way, congratulate the hon. Member for Harrogate and Knaresborough (Mr. Willis) on securing the debate. I share the concerns that he raised and welcome his interest. I join him in acknowledging the important work of the all-party group on population. I was interested in his description of eRanger, particularly as it is a social enterprise, and as the vehicles it facilitates the building of are delivered through a co-operative. As chair of the Co-operative party and a Co-operative MP, I have a particular ideological interest in the business model he is promoting. He asked several questions and asked for a number of assurances, which I shall come to. I shall respond initially by giving some context to the debate.

As the hon. Gentleman rightly said, female mortality is a critical development issue: it is central to three of the millennium development goals, which the international community and the British Government are striving to support the achievement of. In many countries, the HIV/AIDS epidemic is slowing, but it is still the leading cause of death for women in Africa. We know that it is young girls who are disproportionately affected, because they have little control over key aspects of their lives, including sexual behaviour, schooling and access to health care, and little ability to mitigate the impacts of the epidemic on other aspects of their lives.

In sub-Saharan Africa, 250,000 women die each year from pregnancy-related complications. In some countries, the figure is much higher. Almost half the maternal deaths occur in just four countries: Nigeria, Democratic Republic of the Congo, Ethiopia and Tanzania. Sierra Leone has one of the highest reported rates; indeed, a woman in Sierra Leone has a one in eight chance of dying due to pregnancy, so the information that the hon. Gentleman provided about the deployment of eRanger vehicles to Sierra Leone gives a further sign of encouragement for us to take from the debate. The other countries with high reported rates are Rwanda, Malawi and Nigeria. In Africa, many women die due to their unequal access and outcomes, based on class, custom, wealth and power. In Nigeria and Malawi, over 70 per cent. of women say that their husbands alone make the decisions regarding their health care—a terrifying statistic that demonstrates the low status of women in some communities.

One strategically encouraging sign has been the commitment—finally—of the United Nations to establishing a gender agency, for the first time bringing together disparate parts of the UN community to create a much more powerful agency, with a high-ranking leader within the UN system. I hope that that will raise the profile of women and give voice to the many women who, as the hon. Gentleman will recognise, are not heard at the moment in the communities in which they live.

The hon. Gentleman knows that it is difficult to measure maternal mortality accurately. While there seems to have been considerable progress in some countries—we can take heart from the example of Zambia—overall, as he rightly says, there has been negligible progress. Skilled attendance at birth is easier to measure. That means of measuring progress in getting support to women is a core component of a strategy to reduce maternal deaths that we are deploying, and which other donors are getting behind. However, that measurement is not always reliable or consistent. Skilled attendance at birth is very low in most of sub-Saharan Africa, reflecting the higher rates of maternal mortality. For example, in Ethiopia only 28 per cent. of pregnant women receive pre-natal care and only 6 per cent. of births are attended by skilled health staff. That gives some indication of the scale of the challenge that the hon. Gentleman rightly alluded to, and which we recognise.

Our efforts are focused on trying to reduce child mortality and, of course, maternal mortality, but also on reducing the spread of HIV/AIDS as part of the overall drive to reduce female mortality. There has been some progress. The average life expectancy of women in Africa, despite the AIDS epidemic, is slowly increasing and now stands at 54 years. There has been a 20 per cent. reduction in child mortality since 1990, but a girl in Africa is still 25 times more likely to die before her fifth birthday than a girl born in the UK.

The hon. Gentleman is absolutely right to say that while there has been progress in some areas, maternal mortality levels remain unacceptably high and progress seems to have stalled. In many countries, as in the UK a century ago, there is still an acceptance that women will die in childbirth. That is compounded by the low social status of women in parts of Africa and by a lack of access to services.

As the hon. Gentleman suggested, a series of key interventions can be made to make a real difference to women’s survival rates. Family planning and access to safe abortion services are crucial examples, as both are often stigmatised, poorly resourced and, in the case of abortion, illegal in some countries.

Sadly, the truth is that there has been inadequate investment in health systems in general and in maternal health in particular for far too long. For an individual family it might be very costly to access care, and the result is that women are left to die at home. Caring for a woman through pregnancy and delivery requires health services that work, with trained and equipped staff. We know that there is a massive shortage of health workers across the continent, and many health systems are so weak that they offer little or no effective care, particularly in critical areas such as family planning, safe abortion and, crucially, obstetric care. The unmet demand for family planning, for example, results in one third of maternal deaths, including the 13 per cent. from unsafe abortion.

I will give a more graphic example of the differences between Africa and Europe and Asia: while over half of sexually active couples in Europe and Asia use contraception, the average prevalence of contraception across the continent of Africa is only 20 per cent. In many countries, particularly in west and central Africa, rates are less than 5 per cent. Access to contraceptives is probably the most cost-effective way of reducing maternal mortality.

The hon. Gentleman and others may well ask what we are doing about such a grim picture. As he said, we have a strategy on maternal mortality and reproductive health, and it is being updated with an evidence paper to help guide our future work and that of other donors. Politically, we are beginning to see an unprecedented international interest in maternal mortality, partly driven by the White Ribbon Alliance, which has been championed by the Prime Minister’s wife, Sarah Brown, and is beginning to catalyse the support of women across the globe and, in particular, the support of African leaders.

The UK has tried to support that process by leading efforts with international partners to develop a broad-based, global consensus for maternal, new-born and child health. That consensus sets out a framework for action, hopefully aligning political will alongside advocacy and finance, behind a set of five agreed policies and priority interventions to try to save the lives of women and children. The financing issues to put those interventions in place are being addressed.

The hon. Gentleman may remember that the high-level taskforce on innovative international financing for health systems, jointly led by the Prime Minister, hosted an event at the UN General Assembly in September, where more than £3 billion was announced to strengthen health systems in developing countries. Leaders from Malawi, Ghana, Liberia, Burundi and Sierra Leone announced expanded access to free health care, which in the long term will result in millions of children and pregnant women gaining access to essential services.

As for my Department’s financing, 15 per cent. of UK development aid goes to health. The UK has committed itself to investing some £6 billion to strengthen health systems until 2015. Much of that money goes to supporting and strengthening general health services. For example, in Ethiopia we have committed some £25 million over four years to increase the number of community health workers tenfold. With our support, access to contraceptives has already increased from just over 20 per cent. to just over 51 per cent. Our support to the health sector in Malawi has contributed to an increase in skilled birth attendance from just under 40 per cent. to some 45 per cent. in 2007-08.

The hon. Gentleman mentioned a number of international organisations, including UNICEF, which does vital work. We help to fund work of UNICEF, the World Health Organisation and UNFPA, which also works in that area.

The hon. Gentleman made a specific plea for further engagement with eRanger, the organisation and social enterprise in his constituency. I am aware that a series of motorcycle and bicycle ambulance schemes are making a real difference. I have seen them in action in Nepal, where they are clearly helping to save lives. I am aware also of the DFID programmes that support eRanger programmes in Malawi and Kenya. The hon. Gentleman asked me to ensure that eRanger sees a copy of the strategy; I am happy to give him that assurance. I would be happy also to follow the example of the Under-Secretary of State for International Development, my hon. Friend the Member for Worcester (Mr. Foster), who met the hon. Gentleman and eRanger; if necessary, I shall meet them again. I shall certainly write to the hon. Gentleman with a contact for eRanger to use; in turn, I hope that that will help eRanger to gain access to the relevant person at the DFID office in-country.

I cannot guarantee that eRanger will always be the contracted organisation. We have to allow the developing countries concerned to take those procurement decisions for themselves. However, I would want social enterprises and co-operatives to have access to the information that will enable them to make their pitch.

Sitting adjourned without Question put (Standing Order No. 10(11)).