By Aku Kwamie, Research Fellow, Ghana Health Service/University of Ghana; Emerging Voice 2012
We gathered at the foot of Mount Meru for three days: 800 researchers, practitioners, advocates, policy-makers and donors, to discuss the state of quality maternal health care. The fact that we were congregated in one of the oldest inhabited regions on Earth, where women and girls had been dying in childbirth – for millennia – was not lost on the delegates.
The conference itself was a typical affair: well organised, with a steady stream of findings. Yet, the question of implementation – how do we actually do it – played on so many lips. There was palpable dissatisfaction that after CEDAW, Nairobi, Cairo, Beijing, we were still here. The maternal health community has been at this for a long time, even longer than the 26 years since the launch of the Safe Motherhood Initiative. When I canvassed my fellow delegates about their optimism – can we make it? – the collective response was overwhelmingly ‘yes’. Why? Because we have more technology, more attention, and more money than ever (attention and money are always nice). Of course progress has been made, yet we still have unanswered questions on an unfinished agenda.
To the clichéd, but true avowal that pregnancy is not a disease, our approaches remain depressingly biomedical. The belief that technology, signed declarations, or more money is the answer, is false. Listening to various presentations, I was reminded of his book The Honour Code, where philosopher Kwame Anthony Appiah discusses the role of honour in moving ‘moral revolutions’ forward. Appiah theorises that transforming societies happens when the integrity of that society’s honour is breached. He shows how this happens, citing examples like foot-binding, duelling, and even the trans-Atlantic slave trade. We change our practices when they come into conflict with honour. When our practices are no longer honourable, we can dismantle them quickly. Radically, this implies that all of our evidence, resources, and political will may well be drops in the ocean, but not the deluge that we require to halt needless maternal deaths once and for all. What we need to improve the quality of maternal care is a moral revolution.
While no one at the conference would disagree that the challenges we face are rooted in power structures, one could not help but notice a few things about the conference itself: that only one-third of the conference steering committee represented countries with the greatest maternal death burden; and less than half of the presentations were from ministries or universities in the ‘south’. With the exception of large delegations from the host country Tanzania, and notably Bangladesh, the low presence of some of the heavy-burden countries was observed. This is not to take away from those present. But it does illustrate that within our own communities, we still have work to do to amplify the voices that need to be heard, and do so without being tokenistic. We cannot lead the charge for moral revolution in the broader world when we maintain the same old structures among ourselves.
The other thing I kept mulling over was the topic of continuity of care that is equitable, accessible, and respectful – was this any different from having strong health systems able to deliver services when and where they are needed? If we centralise the quality of women’s lives, then our health systems should serve them well at all points during those lives. This also includes those women who provide the bulk of services and are ill-served by the systems in which they work. As we wrote last year (and is outlined in a proposed manifesto for maternal health), the brutality of maternal death is that it occurs where the social, economic, and political disempowerment of women intersect, during a vulnerable period in their lives. In such complex systems, the future is not knowable. But this also means the future is not a given, and change, from an unexpected place is possible.
On the conference’s opening day, the excellent Dr Agnes Binagwaho, whose energising comments have been highlighted elsewhere, noted the coincidence of the Reverend Dr Martin Luther King Jr.’s birthday, by quoting: “True compassion is more than flinging a coin to a beggar; it comes to see that an edifice which produces beggars needs restructuring.” Our edifices are our disciplines, our systems and our funding streams. We need to find new ways of building our communities so that we can change our broader societies. This is particularly true on the eve of a new, post-MDG agenda, the topic of which was raised during the conference only by those with an international view, while those managing the daily crises in communities and facilities remained focused on just that.
We need a moral revolution in maternal health care. If ‘Arusha’ becomes another name on the list as we wait for another 26 years, would there be any honour in that?