Aku KwamieBy Aku Kwamie, Research Fellow, Ghana Health Service/University of Ghana; Emerging Voice 2012

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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?

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4 Responses to 26 Years On: A Need for a Moral Revolution in Maternal Health Care

  1. aku says:

    Dear all,

    It has been interesting to read these comments, and a recent development here enables me to respond.

    You may have seen coverage on a new Ghanaian initiative, the Maternal Health Channel (it was mentioned in last Friday’s IHP newsletter). I was at the launch, and it was so interesting, and not just for the expected reasons.

    An initiative of a local media production company (Creative Storm), and with support from the Netherlands and other development partners, the Maternal Health Channel will run as a weekly television programme: mashed-up docu-drama and panel sessions engaging civil societies, community representatives, private sector, clinical experts, and policy-makers. This is to be combined with radio programming in local languages, and social media. The event was rather high-level: approaching the National Theatre, I was struck by the colourful banners I could see from the street – and the military detail as we awaited the President.

    In Ghana, maternal mortality was declared a ‘national emergency’ in 2008, a fact that is frequently mentioned. It is encouraging to see the new administration continue to prioritise this. In bleakest terms, our mortality and morbidity figures amount to 10 maternal deaths a day, and 270 maternity-related injuries and disabilities daily.

    The Maternal Health Channel is endorsed by specialists, policy-makers, parliamentarians, queen mothers, students, front-line staff, pregnant women, international NGOs and donors alike. It is supposed to be about education, information, discussion, and advocacy. We are supposed to watch/listen ‘en groupe’, and discuss what we think with our sisters, neighbours, nurses, and husbands. I am not much of a television watcher. But my Thursday nights will be booked for the next little while.

    The half-day launch was full of speeches which were interspersed with a trio singing odes to our mothers, and a sketch dramatizing one woman’s treacherous journey at the onset of labour. Notable was the representation of the President by the Minister of Foreign Affairs, an interesting choice, who also spoke eloquently about being the daughter of an ob-gyn, and losing an auntie to an ectopic pregnancy. But there were two main highlights of the day. The first was Madam Lucy, who spoke of her anguish in losing her daughter during her daughter’s pregnancy. In the video clip presented she spoke in Ewe and said of the moment the doctor informed her of her daughter’s death: “my heart cut”. In the translated sub-title it read: “my heart jumped”. There were murmurs as the young nursing students around me giggled and shook their heads at the rendering of this woman’s words. When Madam Lucy took to the stage to tell her story live, she re-iterated her own words in clear English: her heart HAD CUT, to the overwhelming cheers of the crowd who supported her unedited voice.

    The other highlight was the inclusion and acknowledgement of a large group of kayayi, the young porter girls who work in the markets, often migrants and homeless, who face huge challenges in accessing health services. Many of them brought their babies. I can’t say I have ever attended any kind of forum where ambassadors and MPs have sat alongside nursing and midwifery students, and kayayi and babies. It was very nice. The launch ended with singing and clapping in the aisles as the trio sang ‘sweet mother’ and the final sketch delivered us a baby – the journey had been successful!

    To bring this all to the comments below, I think the Maternal Health Channel is a sign that at least in a small way, power and position and resources are listening. Only time will tell if the trends reverse. But moving the dialogue of maternal mortality and morbidity – not just slogans and platitudes – out of clinics, into a broader public domain, is certainly a start. There are changing perceptions of maternal death and disability as being a purely health (services)-relate issues. There is a recognition that the solutions are not only with doctors and politicians, and that sexual and reproductive health rights need debating in this country. As balloons floated around the National Theatre at the end of the launch, the atmosphere was no longer one of distress. There was a glimmer of hope as we honoured the memory of Madam Lucy’s daughter.

  2. Echoka Elizabeth says:

    Dear Aku,
    Many thanks for raising your voice Aku. But my worry is, are the men and women who hold power and position and the resources to reverse the trends in maternal mortality in most of our developing countries hearing you?

    It is unfortunate that those who hold the key to this puzzle continue to congregate and coin slogans like “no woman should die while giving birth” by Ministers of Health, in Addis Ababa in May 2009. Yet, the African saying “a pregnant woman has one foot in the grave” continues to be a blunt reality for most women in most developing countries.

    Like the humming bird story, we shouldn’t look back and dwell on what someone else should have done.We have all have a role to play. Aku, your role in raising the voice of some woman, in some village, who has no access to emergency obstetric care services, is well executed. I throw a challenge to the rest of womankind and the men out there who really care about the slogan, “no woman should die while giving birth” to raise up and ACT.

  3. Rachel Hammonds says:

    Dear Aku,
    You make a very important point – our interventions and thinking have been overwhelmingly bio-medical. Bio-medical interventions are necessary but not sufficent.
    I am ashamed to live in a world where pregnancy is a death sentence for almost three hundred thousands women every year. I am ashamed because progress in pushing the numbers down is too slow. The MDGs were not ambitous enough and still many countries will fail to meet them.
    I find it hard to understand why this global disgrace is not met with moral outrage by people the world over. Numerous UN bodies have issued Declarations on how important this fight is. Does that message get down to the communities that suffer most? I think women continue to die in agony feeling that theier suffering and death is acceptable – and their famillies are not empowered to call for change. The people who live in high-burden countries, high burden areas need to be heard. This ‘greatest global health inequity’ should shame us all.
    I do believe this can change- in part by adopting a more holistic rights based approach to fighting maternal mortality. Giving voice to those at risk, or who suffer most (their relatives, including the motherless children) and validating their outrage and immense loss by pushing for change is a first step. The World needs to be held accountable. We need a body with teeth that holds the international community and countries accountable for their failing to respect, protect and fulfill the rights of women.
    Aku, thank you so much for raising your voice,
    Rachel

  4. Dossou Jean-Paul says:

    Dear Aku,

    This is a great point with a clear and strong argumentation which convinced me, personnaly. The moral revolution you are calling for is essentially the job of the new generation of researchers like you, like me, like Emerging Voices because our mind remains more flexible.
    This post is a good start point to think deeply about what must be the new orientation and how we can start to implement it as soon as possible.
    Congratulations Aku. Thank you.

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