Global maternal health and newborn health: Looking backwards to learn from history

Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2016) 1e11

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Global maternal health and newborn health: Looking backwards to learn from history € m, MD, PhD, Professor * Staffan Bergstro €rbro, Sweden Rute, Alvans 389, SE-624 58 La

Keywords: maternal mortality stillbirth neonatal mortality tropical medicine demography human rights

The late appearance of the ‘M’ on the international health agenda e in its own right and not just as a carrier of the intrauterine passenger e is thought-provoking. The ‘M’ was absent for decades in textbooks of ‘tropical medicine’ until the rhetoric question was formulated: ‘Where is the “M” in MCH?’ The selective antenatal ‘high-risk approach’ gained momentum but had to give way to the fact that all pregnant women are at risk due to unforeseeable complications. In order to provide trained staff to master such complications in impoverished rural areas (with no doctors), some countries have embarked on training of non-physician clinicians/ associate clinicians for major surgery with excellent results in ‘task-shifting’ practice. The alleged but non-existent ‘human right’ to survive birth demonstrates that there have been no concrete accountability and no ‘legal teeth’ to make a failing accountability legally actionable to guarantee such a right. © 2016 Published by Elsevier Ltd.

Looking backwards to learn from history is always a useful exercise. The author has opted to trace a few initial leads, entitled ‘Where was the “M” … ?’ By doing this, the point of departure is Rosenfield's and Maine's now classical article from 1985 e more than 30 years ago e ‘Where is the “M” in MCH?’ [1]. Because this chapter is retrospective, the author chose to write these leads in the past tense as an ingress to this retrospection: tropical medicine, demography and maternal and child health (MCH). Where was the ‘M’ in tropical medicine? Since the inception of the discipline ‘tropical’ medicine, its textbooks almost never paid any discernible attention to maternal health per se, even if it was obvious to all ‘tropical’ doctors that * Tel.: þ46 73 573 27 41. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.bpobgyn.2016.05.010 1521-6934/© 2016 Published by Elsevier Ltd.

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obstetric problems were e and are e extremely common and that the toll taken by maternal and neonatal ill health in the “tropics” was e and is e enormous [2]. For decades, textbooks in tropical medicine have notoriously omitted obstetrics. This is strange as the vast majority of all maternal and perinatal deaths occur in ‘tropical’ countries. As a ‘tropical’ doctor 40 years ago during the war in Angola (1975e76), the author discovered that studying textbooks in tropical medicine never gave any information on issues that are very prevalent in the ‘tropics’ such as eclampsia, obstructed labour, postpartum haemorrhage, maternal mortality or stillbirth. We can, for instance, certainly assume that any world epidemiology map of eclampsia incidence would be reasonably similar to the corresponding map of, for example, malaria. Still the word ‘eclampsia’ could never be encountered under ‘e’ in the index of textbooks in ‘tropical’ medicine. From the beginning, specialists of ‘tropical’ medicine in European countries were not specialists in medical problems in the tropics but rather merely experts in ‘travel medicine’, essentially taking care of (homecoming) Europeans' ‘tropical’ diseases. Of course, there were no homecoming travellers with eclampsia, obstructed labour or postpartum haemorrhage. So this bias is an important reminder of the character of textbooks in ‘tropical’ medicine 40e50 years ago and very often even today. In fact, it is well known that several countries in the tropics e such as Cuba e have a ‘tropical’ disease pattern quite different from other countries at similar latitudes. At the same time, we know that in some currently high-income countries very far from the tropics, for example, Sweden, malaria, leprosy, cholera, etc. were rampant 200e300 years back, making these diseases hardly ‘tropical’ but rather diseases of poverty. The expression ‘pathology of poverty’ has been coined to illustrate this association [3]. The difference in perception e considering today's Cuba and historical Sweden e also represents an attitudinal shift in understanding the complexity of ‘tropical’ diseases caught in the rhetoric question: ‘their latitudes or our attitudes?’ [3]. Currently, the perception of ‘global’ medicine has widened the scope not only geographically but also discipline-wise, and maternal and neonatal health has entered the field in an appropriate way [2,4]. We have turned our attention from the tropics to the planet as a whole, and by that maternal and neonatal health has appeared as two obvious priority fields of intervention. Where was the ‘M’ in the ‘baby bomb’ era? Looking backwards, it is obvious that the late recognition in low-income countries of maternal and neonatal ill health in general has to do with the powerful setting of priorities by influential donor countries and international organizations. The demographic focus on ‘the population explosion’ rather undermined any donor interest to reduce maternal mortality or to pay attention to maternal and neonatal health [5,6]. One particularly revealing example is from a meeting of all Scandinavian professors of obstetrics and gynaecology in Uppsala, Sweden, in the late 1980s. When the author lectured on the need to reduce maternal mortality, a question came from one of the most prominent Swedish professors in obstetrics and gynaecology at the time: ‘Would not reducing maternal mortality imply that the population explosion will worsen?’ He was not alone in seeing enhanced maternal survival as potentially dangerous and problematic. But he was ignorant about the fertility trends showing, already then, the levelling off of global population growth. Notwithstanding this, the mere expression of doubt whether it would be wise to save mothers' lives is of course ethically unacceptable by any standard. In the 1980s, the ‘M’ was also virtually invisible in research priorities supported by major international donors. Less than 5% of the funding in ‘reproductive health’ research in the HRP (Special Programme on Research in Human Reproduction) was spent on maternal health; the remaining bulk supported contraceptive research (Sterky, personal communication). The Swedish professor's questioning of the wisdom of reducing maternal mortality is a thoughtprovoking illustration of the famous statement by Professor Mahmoud Fathalla, quoted innumerable times: ‘Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.’ €m S, Global maternal health and newborn health: Looking Please cite this article in press as: Bergstro backwards to learn from history, Best Practice & Research Clinical Obstetrics and Gynaecology (2016), http://dx.doi.org/10.1016/j.bpobgyn.2016.05.010

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At the same time, powerful donors, such as the World Bank, had not yet started to see the value of financial support to curb maternal and neonatal morbidity and mortality. It came later, particularly evident in 1994, in the ground-breaking annual report: ‘Investing in Health’ [7]. Before that, in the 1970s and 1980s, the World Bank invested overwhelmingly in ‘population’, a very unclear concept e implicitly but not explicitly e implying simply population control or provision of contraceptives. India is a thought-provoking example, thoroughly investigated by the Norwegian researcher Synnøve Engh [8]. Sweden was one of the most prominent donors even before the violent population control-oriented ‘emergency’ was declared in 1975. Sweden entered after the emergency, with the World Bank, in a second big population control project but abolished its participation in 1980 due to the absence of maternal health in it [8]. In India, maternal health had e seemingly e been on the agenda already in the early 1970s by the remarkable legalization of induced abortion in 1971, but it had a demographic motivation, which is obvious when analysing the absence of other commitments to improve maternal health and to reduce maternal and neonatal mortality. Globally, some of the most prominent causes of maternal mortality e also in India e were already at that time postpartum complications such as bleeding from an atonic uterus, uterine rupture and childbed fever. Interestingly, already 50 years ago the postpartum period was given attention in India. In Engh's scientific work [8, p. 194], it is stated that the postpartum programme had grown out of an international project started in 1966 by the Population Council, an American philanthropic organisation working with population control and family planning, which two Indian hospitals participated in. In 1969, the GoI set up its own nationwide Post Partum Programme, based on the international programme. But the postpartum programme had nothing to do with obstetric care at birth and was totally geared towards exerting pressure on postpartum women to accept tubal ligation or other birth control methods [8]. In itself, such a focus was (and is) of course uncontroversial. What is interesting here, however, is that this programme had no maternal health objective but only a demographic one, disguised in an allegedly maternal health costume. The demographic objective soon became dismantled in the ‘emergency’ and signified a virtual abolition of any efforts to enhance maternal and neonatal survival [5]. Engh states: In June 1975, Indira Gandhi declared a national emergency, which lasted until January 1977. During this period, most of her principal opponents were arrested, civil rights were abrogated, and many organisations were banned. The press was heavily censored, journalists were jailed, and foreign correspondents expelled. On 16 April 1976 a new National Population Policy was announced, which contained a range of comprehensive measures, the most extreme being the permission to State legislatures to pass laws for compulsory sterilization. [8, p. 215] The notion that high parity per se is detrimental to women's health is unproven. Observations from Nigeria [9] indicate that high parity is not associated with high mortality per se. Rather, if the investigated mothers are stratified socio-economically, it emerges that it is not parity but poverty that kills [9,10]. In an overview of poverty-stricken, historical Sweden regarding the degree of risk attributable to multiparity per se for adverse pregnancy outcome, we found essentially the same thing: that grand multiparity is not a risk factor for maternal death [5,11]. A similar approach was used in Bangladesh where birth intervals per se were not found to be associated with increased risk of maternal mortality [12]. In retrospective, the era of the ‘baby bomb’ hoax made maternal and neonatal survival a lowpriority issue, which delayed the recognition of the ‘M’ in its own right. Notwithstanding the importance of contraceptive access as a tool for women's emancipation and freedom, the nonrecognition of maternal health as a human right implied a delay in recognizing the ‘M’ during this era [13,14]. Attention was consequently drawn to ‘reproductive health’ as a wider concept than ‘family planning’ and subsequently ‘family welfare’, the latter representing essentially a new name for population control in India [13]. In fact, the concept ‘reproductive health’ was coined for the first time only in 1985 [15].

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Where was the ‘M’ in MCH? After the Alma Ata conference in 1978, primary healthcare gained recognition and the concept MCH was created as a parole. Save the Children (founded already in 1919), UNICEF (founded in 1946) and other organizations working for children had gained momentum over several decades and the woman with the baby on her back became the incarnation proper of the MCH concept. But the ‘C’ became much more prominent than the ‘M’, the latter being more a carrier (of the ‘C’) than an individual in its own right. Also, the Asian focus on the threatening ‘baby bomb’, during the emergency in India, presumably added to the perception of the burden of many babies. For obstetricians, the background position of the ‘M’ became gradually an eye-opener [10]. In the same year, incidentally, Rosenfield and Maine published their now famous article: ‘Maternal mortality e a neglected tragedy e Where is the M in MCH?’ [1]. The article challenged the obstetricians to be more proactive and show more initiative. The authors stated: It is difficult to understand why maternal mortality receives so little serious attention from health professionals, policy makers, and politicians. The world's obstetricians are particularly neglectful of their duty in this regard. Instead of drawing attention to the problem and lobbying for major programmes and changes in priorities, most obstetricians concentrate on subspecialties that put emphasis on high technology. [1, p 83] Alluding to the World Bank's focus on population control and unclear focus on maternal health, they concluded: We suggest that the Bank makes maternity care one of its priorities. A programme for the prevention of maternal deaths could be built around the building of maternity centres in rural areas, the recruitment and training of staff for the centres, and the provision of supplies and drugs. The programme could be phased so that governments would take over these expenses in time. Loans for these purposes should be seen as an acceptable long-term investment in improving the health of women. [1, p 85] Two years after Rosenfield's and Maine's article, the first Safe Motherhood Conference took place in Nairobi in 1987 and maternal health, for the first time, was given global attention. Motherhood- and pregnancy-related health became emerging priorities. Morbidity and mortality around birth (perinatal) became important issues to address. Perinatal medicine emerged as an earlier overlooked and neglected discipline. From becoming a paediatric subspecialty, it had more and more an obstetric identity, though, like in the case of MCH, ‘M’ was again subordinate to ‘C’. The fact that about 70% of maternal deaths occur in the perinatal period raised a rhetoric question similar to the one raised by Rosenfield and Maine: ‘Is there an “M” in perinatal medicine?’ [16]. The seven years from Nairobi (1987) to the Cairo ICPD International Conference on Population and Development (1994) visualized further that the ‘M’ had finally gained more visible recognition. Several other global conferences in the early 1990s took the challenges of the Safe Motherhood Conference seriously and formulated the goal of halving maternal mortality by the year 2000 [17]. One of the most important events was the ‘World Summit for Children’ in 1991 (with more than 120 heads of state and presidents present), which predated the Cairo commitment of reducing maternal mortality by half by the turn of the century [18]. The MCH concept was useful to draw attention to the importance of the mother for the survival and well-being of the newborn. But the picture that we associate with the MCH concept is incomplete. It says nothing of maternal health and hides one brutal aspect of the mother: when the woman is dying a maternal death, the baby is never on her back. The simplistic shortcut: antenatal classification of the high-risk mother In the 1970s, the World Health Organization (WHO) had launched ‘the risk approach’ as a strategy in antenatal care to identify risk factors for undesirable outcomes, with care to be delivered according to €m S, Global maternal health and newborn health: Looking Please cite this article in press as: Bergstro backwards to learn from history, Best Practice & Research Clinical Obstetrics and Gynaecology (2016), http://dx.doi.org/10.1016/j.bpobgyn.2016.05.010

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individual needs. A WHO compilation on coverage of maternity care [19] showed that while almost all pregnant women in high-income countries attend antenatal care, most of them from the first trimester onwards, less than two-thirds receive antenatal care in most countries in low-income countries [20]. Over the last decades, a number of trials have addressed the question if any antenatal care model is superior to the others. One randomized controlled trial in Zimbabwe tested a model of fewer but more objectively oriented visits and fewer procedures per visit [21]. Women in the new programme had fewer visits, less antenatal referrals and significantly less preterm deliveries, and there were no differences in other outcome indicators. It is obvious that there are categories of women with foreseeable problems at a forthcoming birth. Examples comprise those with short stature, diabetes, hypertension, previous caesarean section, etc. But it is likewise true that among the vast majority of women who actually die, the prevalence of conventional ‘risk’ factors is low and most women dying a maternal death are, in fact, low-risk women [22]. This implies that screening for ‘high risk’ is a necessary but not sufficient precondition for making pregnancy safer. In 1997 in Colombo, there was a celebration of the tenth anniversary of the Safe Motherhood Initiative in Nairobi. This celebration conference shaped the important conclusion: ‘every pregnancy faces risk’, thereby admitting that the problem of maternal mortality is dependent, in the majority of cases, on factors and circumstances occurring very suddenly, without warning also, in otherwise healthy individuals [23]. The need for emergency obstetric care with proper management of such ‘bolts from the blue’ became obvious. For instance, with active management of the third stage of labour the risk of massive postpartum haemorrhage can be reduced. However, if it occurs, unexpectedly, both external compression of the abdominal aorta and applying the intrauterine condom tamponade technique (with or without retained placenta) will stop bleeding in most cases and save the woman's life [24]. For another ‘bolt from the blue’, eclampsia, a similar emergency regimen is needed. Even if mostly preceded by pre-eclampsia, some eclampsia cases have short prodromal stages. It has its ‘management of choice’ with magnesium sulphate in bolus and maintenance doses and with clinical control of patellar reflexes, respiratory rate and hourly urinary output. Both these ‘bolts’ can be handled by a midwife in a small peripheral unit and both categories can, but only if needed, be referred to the first referral level. Pregnancy has two ‘actors’: the carrier and the passenger. And safe motherhood also comprises the safe birth of a live passenger. Looking backwards, it is thought-provoking that the attention paid to stillbirths and early neonatal deaths has been so limited. Even the global burden of disease concept long overlooked ‘stillbirth’ as an entity. In the ‘Global Burden of Disease’ of 2004, the concept ‘stillbirth’ was not even mentioned at all [25], in spite of the fact that more than three million stillbirths occur annually [26]. In addition, each year approximately three million newborns die before they are 1 month old, contributing to about 40% of all deaths of children under 5 years of age and 60% of all infant mortalities [27]. Human resources attending birth: from traditional birth attendants (TBAs) to major obstetric surgery by midwives Looking backwards, it is thought-provoking to note that the issue of human resources to reduce maternal and perinatal mortality has been given global attention fairly late. It can be demonstrated that higher health worker density is clearly correlated with lower maternal and perinatal mortality [28]. On a global scale, according to the WHO (2014) there is a current deficit of about 7.2 million skilled health professionals. A projection model based on estimations of the population growth would lead to a global deficit of about 12.9 million health workers by the year 2035 [29]. The scaling up of the projected requirements for maternal, newborn and child health assumes the global production in the next ten years of at least 334,000 additional midwives (or professionals with midwifery skills) and the upgrading of 140,000 others [30]. Some 27,000 doctors and technicians have to learn the skills to provide backup maternal and newborn care, and 100,000 full-time equivalent multipurpose professionals have to learn to follow up maternal newborn care with integrated childcare [30]. Looking backwards, there is a tremendous backlog in the number of available professionals with midwifery skills. The world has failed in providing skilled midwives to match the unmet need of skilled €m S, Global maternal health and newborn health: Looking Please cite this article in press as: Bergstro backwards to learn from history, Best Practice & Research Clinical Obstetrics and Gynaecology (2016), http://dx.doi.org/10.1016/j.bpobgyn.2016.05.010

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attendants at birth. Worldwide, approximately two-thirds of all approximately 138 million births occur outside health facilities [31]. The majority of them, around 60 million deliveries per annum, are currently attended by a traditional birth attendant (TBA), a relative or, in some settings, no one [32]. These estimates can be expected to increase as rising numbers of young girls enter the reproductive age group. Significant midwifery training and deployment costs, which include salaries, housing and rural posting allowances, are inevitable. In addition to these direct costs, there may be additional costs related to supervision and support. Non-governmental organizations, working at the community level in resource-poor countries, frequently include TBA training in their activities. A number of governments, for example Bangladesh, have also adopted this approach, supported by massive donor funding. International agencies, including WHO, UNICEF and UNFPA, have also supported TBA training in the past. However, in recent years, the value of TBA training has been increasingly questioned, although there are still groups who, since many years, remain enthusiastic [33]. Several studies report that TBAs practice what they have learnt during their subsequent work in the community [34]. However, adoption of improved practices is not universal and the extra confidence gained from the training experience may lead to a higher incidence of dangerous procedures and sometimes delays in referral [35]. There is also evidence that training does not substantially alter the belief systems of TBAs and might therefore have little impact on practices that are rooted in these beliefs [36]. Reports of the TBA training programme in Faisalabad City, Pakistan, attribute falls in measles, mumps and rubella (MMR) to the programme. Before the programme, MMR was estimated at 10.1/1000 live births. This had fallen to 1.9/1000 by 1987 and to 0.64/1000 by 1993. However, many other improvements in obstetric services were implemented over the same time period, including an obstetric flying squad service and subsidies for obstetric care in hospital. No statistical analysis is reported [37]. A prospective study in Nigeria studied changes in MMR following the training of 75 TBAs within a 10-mile radius of a referral hospital. Maternal deaths dropped by 50% (30 to 15) in the 3 years following the training. Non-randomly selected comparison areas were more distant from the hospital. The maternal deaths in these sites dropped by 27% (34 to 25) in the same time period. Statistical analysis was not performed [38]. Looking backwards, there have been few published reports of maternal morbidity as an outcome of TBA training programmes. However, two recent studies suggest that the impact is not likely to be important. One study in Bangladesh showed that although trained TBAs were significantly more likely to practice hygienic delivery than untrained TBAs (45% vs. 19.3%, p < 0.0001), there was no significant difference in levels of postpartum infection when deliveries by trained TBAs and untrained TBAs were compared [39]. A study by Johkio et al in Pakistan has demonstrated convincingly that perinatal mortality can be reduced by a carefully designed programme in which TBAs are integrated in the health system [40]. Basic emergency obstetric care by TBAs has its supporters, but what about comprehensive emergency obstetric care (CEmOC)? CEmOC implies major surgery, for example, caesarean sections, even where there are no doctors. How can that be possible? In the 1980s, during the apartheid-led civil war in Mozambique, the unmet needs for emergency healthcare and life-saving skills in rural areas were noticeable in two fields: obstetric emergencies and war casualties. In 1984, a training course was therefore initiated, aiming at creating a new category of cnicos de cirurgia’ (corresponding to surgically trained assistant mid-level providers of healthcare, ‘te medical officers in Tanzania and clinical officers in Malawi) [41,42]. cnicos de cirurgia’ is dominated by obstetrics and gynaecology, trauma care The work burden of ‘te and abdominal emergencies, the first category amounting to around 40% of the total surgical burden. In 2004, this problem prompted the Higher Institute of Health Sciences (ISCISA) in Maputo to start a 3.5year training of two categories of applicants: firstly, experienced midwives and, secondly, secondary school graduates (without midwifery training), to perform emergency obstetric surgery themselves in cnicos de cirurgia’ from most of the burden order to strengthen the surgical rural team and alleviate ‘te of obstetric and gynaecological surgery [43]. After graduation, they are called ‘enfermeiras licenciadas de saúde materna’ or ELSM (licentiate maternal health nurses). The reason to include the two categories mentioned earlier was the scarcity of recruitable midwives for the ELSM training and the €m S, Global maternal health and newborn health: Looking Please cite this article in press as: Bergstro backwards to learn from history, Best Practice & Research Clinical Obstetrics and Gynaecology (2016), http://dx.doi.org/10.1016/j.bpobgyn.2016.05.010

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cnicos de cirurgia’ from their work burden. Already at intention to meet the need of staff to relieve ‘te the inception of the first batch of ELSM students in 2004, the recruitment of students without formal midwifery training was subject to intense discussion. The decision was finally taken to allow both categories into the ELSM training. Subsequently, it has been decided to recruit merely experienced midwives for this ELSM training (Pereira, personal communication). These midwifery trainees have three years of midwifery training and several years of midwifery experience when they apply to undergo the ELSM training. It comprises three years of theoretical and practical training in obstetric and gynaecologic surgery in Maputo followed by half a year of internship supervised by qualified obstetricians and surgeons at a regional hospital. The focus of this training is on three major emergency surgeries: caesarean section, obstetric hysterectomy and laparotomy for removal of ectopic pregnancy and for drainage of pelvic infection. Looking backwards and forwards: the health-system response to ill health of pregnancy carrier and passenger is decentralization and task-shifting Decades ago, Deborah Maine assessed the relative cost-effectiveness of seven hypothetical models of maternity care: conventionally trained TBAs, TBAs with further training, prenatal care for all women, family planning to prevent 20% of pregnancies, health centres with transport to an urban hospital, health centres without transport to an urban hospital and, finally, health centres with transport to several rural hospitals. It turned out that, in a high-maternal mortality situation, where direct obstetric causes account for most maternal deaths, investment in health centres and rural hospitals proved to be the most cost-effective option in terms of maternal deaths averted per dollar spent [44]. Maine's now classical conclusion has resulted in a growing recognition of the need to have lifesaving skills immediately available close to where the most severe complications occur. Looking backwards, her insight in combination with her emphasis of ‘the three delays’ is presumably the most fundamental contribution to the enhanced maternal and perinatal survival we can verify despite shortcomings in the attainment of Millennium Development Goal (MDG) 5. Two concrete consequences are, firstly, the decentralized focus on health centres (rather than rural hospitals) for CEmOC (including major obstetric surgery) that has been implemented in, for instance, Tanzania [45], and secondly, the assignment of well-trained ‘non-physician clinicians’ (NPCs) or more correctly ‘associate clinicians’ at such peripheral health facilities, extensively researched in Mozambique, demonstrating that task-shifting is a valid solution to the pressing problem of scarcity of human resources to handle unmet needs also in major obstetric surgery [46]. Our studies and other literature show that mid-level health professionals carry out the majority of surgical procedures outside urban areas in a number of Sub-Saharan African countries and are indiscnicos de cirurgia in pensable when physicians are scarce [47e50]. The studies indicate that te Mozambique perform 92% of caesarean sections in first-level hospitals [51,52]. In Tanzania, surgically trained assistant medical officers perform 85% of caesarean sections, 94% of repairs of ruptured uterus, 86% of removals of ectopic pregnancy and 70% of hysterectomies in the Mwanza and Kigoma regions in Tanzania [46,50]. The shortage of skilled human resources in surgical healthcare is a major health system problem in Mozambique and Tanzania, as well as in other low-income countries. Innovative and multifaceted workforce solutions offer viable options for alleviating the consequences of the shortage and building the capacity of countries to provide skilled surgical care. Task-shifting is a feasible strategy and should be seriously considered to address the human resources crisis in Mozambique and Tanzania, as well as in other countries facing the same human resources problems [46]. cnicos de A comparison of the quality of care provided by medical doctors and that provided by te cirurgia in Mozambique demonstrates no clinically significant differences in outcomes in major obstetric surgery [51]. In Mozambique, physicians (general practitioners and specialists), nurses and cnicos de cirurgia positively [48] and they have a high retention rate e almost 90% e midwives rate te after seven years of first assignment at the district level [52]. These associate clinicians/NPCs are costeffective, and the training and deployment of them in Mozambique are three times more cost-effective than the training and deployment of medical doctors [53]. Motivation is, however, a problem among them for multiple reasons, and programmes are being developed to address some of the causes. €m S, Global maternal health and newborn health: Looking Please cite this article in press as: Bergstro backwards to learn from history, Best Practice & Research Clinical Obstetrics and Gynaecology (2016), http://dx.doi.org/10.1016/j.bpobgyn.2016.05.010

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Challenges continue for many countries in physicians' acceptance of mid-level clinicians; the development and implementation of training and regulatory mechanisms; the expansion of the capacity for skills development and improvement, as well as supervision, and better financial and non-financial compensation [46]. Looking backwards: was surviving birth ever a real human right with ‘legal teeth’? There are many eloquent commitments on maternal health as a human right in the wake of the MDG 5 discussions since the turn of the century. More often than not, there seems to have been more eloquence than substance in such commitments. In a Lancet article in 2008, the Canadian researcher Susan Erikson wrote these thought-provoking words: ‘Imagine health as a human right with legal teeth, replacing the current mechanisms that require nation states to provide protections for their citizens, even when that same state is a perpetrator.’ [54] Few relevant published documents contribute tangibly to launching ‘maternal health’ as a human right. It appears that there is not a single one with ‘legal teeth’. One often-quoted document is ‘Technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal morbidity and mortality’ (Report of the Office of the United Nations High Commissioner for Human Rights) [55]. It does not, however, provide any actionable tool for measures to be taken in case of even clear violations of maternal health as a human right. In the document (17 pages), the word ‘should’ is encountered 78 times and the word ‘must’ 18 times. This indicates that the power of accountability (governments, politicians, parliamentarians) is absent: no one will be brought to any court after violation of maternal health as a human right. This document is a remarkable example of legal toothlessness and absence of ‘maternal health as a human right with legal teeth’. When the author of this article a few years ago addressed more than 1000 obstetriciangynaecologists at an annual conference of the Sudanese Association of Obstetrics and Gynaecology in Khartoum with a keynote on maternal mortality, one of the participants stood up and asked the question: ‘Don't you think maternal deaths should be considered a crime against humanity e due to the systematic inaction by governments, with continuous violations of maternal health rights?’ For a few seconds, the author was speechless but finally admitted that, yes, those politicians who accept continuous violations of mothers' survival without taking action might well be called ‘perpetrators’, as they actually have the power but do not act sufficiently against these violations. But professionals in international law say that a ‘crime against humanity’ requires proven intention, which e in the case of neglected maternal deaths e will never be possible to prove in any other way than by indirect evidence. The conclusion in Khartoum was that ‘any government has the maternal mortality it deserves’, which might be challenging enough for some governments to show more than verbal lip service in policy documents, rather than to show actionable competence. In the preparations for the Millennium Declaration in 2000, there was a significant political backlash from several global entities, ranging from the G-77 to pressures from the Vatican, conservative Islamic states and evangelical Christians in the United States [56,57]. In the same way, experiences after the International Conference on Population and Development (ICPD) in Cairo show the importance of operationalizing the human rights perspective in order to convert aspirational ideals into actionable tools. Multiple fact-finding reports on maternal mortality in different countries have implied pressure on governments, in terms of changes in policies [58]. Social accountability strategies and citizen budget analysis now enable civil society citizens to monitor their own health facilities and act on policymaking authorities [59e61]. In Kenya, public riots have attracted mass media attention to egregious abuses carried out against women at the biggest public maternities, such as Pumwani Maternity Hospital in Nairobi [62]: Detention of women who cannot pay their medical bills for maternity or other services occurs in both public and private facilities. Private facilities generally use detention to pressure the patient's relatives to pay the bill. Public facilities also use detention for this purpose and to determine whether or €m S, Global maternal health and newborn health: Looking Please cite this article in press as: Bergstro backwards to learn from history, Best Practice & Research Clinical Obstetrics and Gynaecology (2016), http://dx.doi.org/10.1016/j.bpobgyn.2016.05.010

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not a patient really is poor enough to qualify for a waiver. Thus, women who have only recently given birth are often forced to sleep on the floor or share a bed with others, are underfed, and suffer verbal abuse from staff over their failure to pay. For women whose babies have died, there is a particular psychological cruelty to being detained in a maternity ward, surrounded by other mothers and their infants. [62, p 8] The Human Rights Council of United Nations (UN) has issued two historic resolutions regarding maternal mortality, which first established the normative connections between maternal mortality and human rights, and in 2012 adopted an important resolution, which should serve as guidance in state reporting under the Universal Periodic Review procedure before the council [55,63]. Moreover, failures of accountability and need for human rights protections were noted in the 2010 UN Secretary-General's Global Strategy on Women and Children, which specifically called upon the WHO to chair an ‘accountability process’ on women's and children's health to implement the global strategy [64]. Operationalization must take many forms, including social accountability efforts as well as judicial enforcement. For the future, there is an urgent need to move away from declaiming abstract principles to concretely depict ways for a different ethical calculus in decision-making. In maternal mortality monitoring, quantitative data need not only be disaggregated to reveal potential disparities and discrimination, but actionable indicators need to be selected that can measure compliance with international human rights obligations [55]. Looking backwards on the ‘human right’ for both actors in pregnancy to survive birth, it demonstrates that there have been no accountability and no ‘legal teeth’ to make failing accountability actionable at the court level. The subsequent lip service, without legal action, will presumably be questioned by future authors looking backwards to what we did not achieve. Summary Looking backwards at all efforts to enhance maternal and neonatal survival is inspiring. The late appearance of the ‘M’ e in its own right and not just as a carrier of the intrauterine passenger e is striking. The ‘M’ was absent for decades in textbooks of ‘tropical medicine’ and continued to be absent during the era of the ‘baby bomb’. Not until the rhetoric question was formulated ‘Where is the “M” in MCH?’ did the issue of maternal mortality appear on the international agenda. The ‘risk approach’ gained momentum until it was understood that, in fact, all women are at risk of life-threatening obstetric complications. Confronting the massive scarcity of human resources for maternal and neonatal health implies an urgent need for training of close to half a million midwives to replace TBAs. In order to address the issue of providing trained staff to master CEmOC including major obstetric surgery such as caesarean sections, obstetric hysterectomies and removals of ectopics, some countries have embarked on training of mid-level providers of healthcare for such surgeries with excellent results. The health system response is at least twofold: firstly, overcoming the rural scarcity of providers of CEmOC by task-shifting after due training and, secondly, by decentralization of such comprehensive care to duly upgraded health centres e beyond rural hospitals. The ‘human right’ to survive birth demonstrates that there have been no accountability and no ‘legal teeth’ to make a failing accountability actionable at the court level to guarantee such a right.

Practice points  We know that maternal and perinatal health should be considered both in conjunction (before delivery) and separately (after the end of pregnancy).  When the mother dies a maternal death, the baby is never on her back and maternal survival should be considered in its own right, which goes beyond MCH care.

€m S, Global maternal health and newborn health: Looking Please cite this article in press as: Bergstro backwards to learn from history, Best Practice & Research Clinical Obstetrics and Gynaecology (2016), http://dx.doi.org/10.1016/j.bpobgyn.2016.05.010

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Research agenda  Outcome of major obstetric surgery performed by surgically trained midwives.  Audit of caesarean sections at district hospital and health centre level in resource-poor settings.  Studies on accountability in violations of maternal healthcare.

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€m S, Global maternal health and newborn health: Looking Please cite this article in press as: Bergstro backwards to learn from history, Best Practice & Research Clinical Obstetrics and Gynaecology (2016), http://dx.doi.org/10.1016/j.bpobgyn.2016.05.010