How much are mothers worth?

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On Women's Health and RightsLectures, Speeches and StatementsMahmoud F. Fathalla

HOW MUCH ARE MOTHERS WORTH ?HOW MUCH ARE MOTHERS WORTH ?

13th World Congress of13th World Congress ofGynaecologyGynaecology and Obstetrics,and Obstetrics,Singapore, September 1991Singapore, September 1991

Why are mothers still losing their lives in the process of pregnancy and childbirth?

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WHY ARE MOTHERS STILL LOSINGWHY ARE MOTHERS STILL LOSINGTHEIR LIVES IN THE PROCESS OFTHEIR LIVES IN THE PROCESS OFPREGNANCY AND CHILDBIRTH?PREGNANCY AND CHILDBIRTH?

The World Health Organization estimates that every year about 500,000 women lose theirlives in the process of pregnancy and childbirth. They do not die from causes which we donot know or which we cannot prevent or treat. The know-how is already available toprevent and/or effectively manage the potential maternity-related life-threateningcomplications. Nor do these women die because of general lack of resources that can betapped to provide the necessary health care interventions. It is true that 99% of maternaldeaths occur in developing countries. However, the high levels of maternal mortality cannotbe considered a direct outcome of poor socio-economic development. For one reason, levelsof maternal mortality vary widely between countries with the same economic level andseveral developing countries with a low or lower middle income economy have broughtdown their maternal mortality rates to low levels

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Grassroot Groups- Developed Countries 3

Safe Motherhood

Maternal Mortality by Income Levels, selected countries

900

150

1400

810

650

70

Vietnam Cambodia Yemen Sri Lanka Bolivia Cote d'Ivoire

Mat

erna

l Dea

ths

per 1

00,0

00 L

ive

Birt

hs

$200 $750 per capita income

Maternal Mortality/Deaths per100,000 Live Births

Countries having the same level of low per capital income can have widely different levelsof maternal mortality. At a low per capita income of $ 250-350, maternal mortality is muchlower in Vietnam (Maternal mortality ratio MMR 160) than in Yemen (MMR 1400) [1]. Atthe higher but still low level of $ 690 to 950, the level in Sri Lanka (140) cannot becompared with that in Bolivia (650) or Cote d’Ivoire (810).

It should also be noted that socio-economic development per se, without the availability andutilization of health care, will not make motherhood much safer. A study conducted in theUnited States compared maternal and perinatal mortality rates among women who weremembers of a religious group in Indiana and who avoided obstetric care, with the statewiderates.2 Members of the religious group had a perinatal mortality rate three times higher anda maternal mortality rate about 100 times higher.

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The tragedy of maternal deaths in theThe tragedy of maternal deaths in theworld today is an issue of priorities in theworld today is an issue of priorities in theallocation of resources. It is a questionallocation of resources. It is a questionof how much mothers are consideredof how much mothers are consideredworth.worth.

What is the monetary value of a woman’s life?


WHY ARE MOTHERS STILL LOSINGWHY ARE MOTHERS STILL LOSINGTHEIR LIVES IN THE PROCESS OFTHEIR LIVES IN THE PROCESS OFPREGNANCY AND CHILDBIRTH?PREGNANCY AND CHILDBIRTH? WHAT IS THE MONETARY VALUE OF AWHAT IS THE MONETARY VALUE OF A

WOMAN'S LIFE ?WOMAN'S LIFE ?

Rational allocation of resources to prevent deaths requires, according to economists, some

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monetary valuation of the life of different individuals.3 This notion may be repugnant to themedical profession who likes to think that nothing is too expensive for the sake of savinglife. However, societies unconsciously or consciously, put such values in their decisionmaking process. One element in the valuation of a human life is how much investmentsociety has made in the individual. Another element is the productivity factor. Sir WilliamPetty, as far back as 1699, advanced a method of valuation that was based on the assumptionthat an individual contributes to society his production, which is equivalent to his earnings.4

This earnings-estimate, adjusted to expectation of working life, provides a commonlyutilized means for calculating the value of human life.

The value system underlying judgment about the monetary value of human life is not simplya question of economics. It is also a question of social ethics, particularly where women areconcerned. Many societies in developing countries tend to invest less in girls than in boysand to underestimate the economic contribution of women. Gender comparisons in 112developing countries show that rates for women, compared to men, were 74% for adultliteracy, 57% for enrollment in higher education and 49% for labour force participation 5. Acommon belief is that women contribute a minor share of the world's economic product.Conventional measures of economic activity

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undercount women's paid labour and do not cover their unpaid labour. It has been estimatedthat the value of women's work in the household alone, if given economic value, would addan estimated one-third to the gross nationalproduct.5

Apart from these social perceptions of a woman's worth, there are medical indicators aswell. In many countries, sex differentials exist in infant and child mortality 6. Anothermedical indicator of concern is the abuse of prenatal sex determination for selective abortionof the female foetus.

Is maternity a disease or a duty?



WOMAN'S LIFE ?WOMAN'S LIFE ? IS MATERNITY A DISEASE OR A DUTY?IS MATERNITY A DISEASE OR A DUTY?

A rational allocation of resources in the health sector demands the ranking of diseases atdifferent levels of priority. This can be done through a rough indicator of a "body count" or in amore refined way by using a criterion such as quality-adjusted life years (QALYs) gained.7

Maternal causes account for 1.3 percent of all deaths in developing countries.8 If maternity isranked as just another disease, its ranking will not be high from an epidemiological approach.The question, however, should be raised as to whether society would be right to rank maternalhealth problems with other diseases. Maternity is a social function. Maternity-related diseasesand injuries are incurred during performance of this social function. Society has more of anobligation for preventing maternal deaths than for preventing deaths from other diseases.

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Where is the M in MCH?



WOMAN'S LIFE ?WOMAN'S LIFE ? IS MATERNITY A DISEASE OR A DUTY?IS MATERNITY A DISEASE OR A DUTY? WHERE IS THE M IN MCH ?WHERE IS THE M IN MCH ?

Resources allocated for maternal health are generally lumped together with resources forchild health in an MCH package.

It is true that maternal health interventions also benefit the child. An expectant mother withno prenatal care, for example, is three times more likely to have a low birth-weight baby.9

However, to save mothers' lives, certain relatively high cost interventions are needed, andmay have less impact on perinatal mortality.

The "M" in MCH has often been seen as a means and not an end, as a means for childhealth. Interventions such as nutrition and prenatal care are often justified on the basis ofthe benefit to the child. Even strategies for mothers' survival are being justified as necessaryfor child survival. Studies have been designed to show that infant mortality increased onlyslightly after the father's death but increased dramatically with the mother's death,particularly for a female child.10

The Plan of Action for implementing the World Declaration on the Survival, Protection andDevelopment of Children in the 1990s tried to address this issue by stating that "Maternalhealth, nutrition and education are important for the survival and well-being of women intheir own right and are key determinants of the health and well-being of the child in earlyinfancy".11

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Where is safe motherhood in primary health care?



WOMAN'S LIFE ?WOMAN'S LIFE ? IS MATERNITY A DISEASE OR A DUTY?IS MATERNITY A DISEASE OR A DUTY? WHERE IS THE M IN MCH ?WHERE IS THE M IN MCH ? WHERE IS SAFE MOTHERHOOD INWHERE IS SAFE MOTHERHOOD IN

PRIMARY HEALTH CARE ?PRIMARY HEALTH CARE ?

Since the Alma Ata international conference on primary health care in 1978, more and morecountries are shifting resources for primary health care. Recently, 81 Member Statesprovided information to WHO on the proportion of national health expenditure devoted toprimary health care. Among these, 19 reported a proportion of 50% or more.12 The averageof these proportions for all Member States was about 35%, with 41% for the leastdeveloped, 34% for the developing and 31% for the industrialized countries. From theavailable date, WHO concluded that though the percentage of GNP spent on health has beenstationary since the 1985 evaluation of health for all strategies, the proportion devoted toprimary health care has increased markedly.

The emphasis in primary health care is on low cost interventions that potentially benefitlarge numbers of people. In the context of maternal health, these relatively low costinterventions include community-based prenatal services, training of traditional birthattendants and provision of family planning services. In spite of all the health benefits ofthese interventions, they are less effective in reducing maternal deaths. A recent study hasestimated that two-thirds of maternal deaths can only be prevented through the provision ofessential obstetric functions at the first referral level.13 Family planning can prevent up to aquarter of maternal deaths, depending on the prevalence of unwanted pregnancies and theavailability or lack of safe pregnancy termination services. Community-based prenatal careand delivery by trained birth attendants, if not backed up by an effective referral system, willonly prevent up to 10 to 15 percent of all maternal deaths.

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Who shall live? Who shall die? Who shall decide?


WHY ARE MOTHERS STILL LOSING THEIRWHY ARE MOTHERS STILL LOSING THEIRLIVES IN THE PROCESS OF PREGNANCY ANDLIVES IN THE PROCESS OF PREGNANCY ANDCHILDBIRTH?CHILDBIRTH? WHAT IS THE MONETARY VALUE OF AWHAT IS THE MONETARY VALUE OF A

WOMAN'S LIFE ?WOMAN'S LIFE ? IS MATERNITY A DISEASE OR A DUTY?IS MATERNITY A DISEASE OR A DUTY? WHERE IS THE M IN MCH ?WHERE IS THE M IN MCH ? WHERE IS SAFE MOTHERHOOD IN PRIMARYWHERE IS SAFE MOTHERHOOD IN PRIMARY

HEALTH CARE ?HEALTH CARE ? WHO SHALL LIVE? WHO SHALL DIE? WHOWHO SHALL LIVE? WHO SHALL DIE? WHO

SHALL DECIDE?SHALL DECIDE?

When resources are limited, decisions have to be made, tough decisions, on who shall liveand who shall die. Decision-makers generally act on their own judgment as to what benefitthey themselves or the society at large could derive from a choice among competing healthinterventions. The benefits are both those assessed scientifically as well as those perceivedsubjectively. Women are a minority among decision makers. Although they comprise 50percent of the world's enfranchised population, women hold no more than 10 percent of theseats in national legislatures; in one government in three there are no women in the highestdecision-making body of the country, and in those cabinets where women are included, thereis usually only one woman.5

Conclusion

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CONCLUSIONCONCLUSION

Adequate allocation of resources to address theAdequate allocation of resources to address thetragedy of maternal mortality will be possible:tragedy of maternal mortality will be possible:-- if women are valued more in their societies,if women are valued more in their societies,-- if maternity is recognized as a social duty for whichif maternity is recognized as a social duty for whichsociety has an obligation,society has an obligation,-- if resource allocation to maternal health is identifiedif resource allocation to maternal health is identifiedwithin the MCH package,within the MCH package,-- if the concept of primary health care is extended toif the concept of primary health care is extended tocover essential obstetric functions at the first referralcover essential obstetric functions at the first referrallevel, andlevel, and-- if more women are involved in the national decisionif more women are involved in the national decision--making process.making process.

REFERENCES

1. World Health Organization. Revised 1990 estimates of maternal mortality.WHO/FRH/MSM/96.11. 1996. P.12-15.

2. Kaunitz, A.M., Spence, C., Danielson, T.S., Rochat, R.W. and Grimes, D.A. (1984): Perinataland maternal mortality in a religious group avoiding obstetric care. Amer. J. Obstet. Gynecol.150. 862-831.

3. Card, W.I. and Mooney, G.H. (1977): What is the monetary value of a human life? Brit. Med.J. 1. 1627-1629.

4. Petty, W. (1699): Political arithmetic. London, Robert Clavel. Quoted by Card and Mooney(1977).

5. Sivard, R.L.. Women ... a world survey. p.39. World Priorities, Washington D.C..

6. Royston, E. and Armstrong, S., Editors (1989): Preventing maternal deaths. p.66. WorldHealth Organization.

7. Kawachi, I., Bethwaite, P., Bethwaite, J. (1990): The use of quality-adjusted life years(QALYs) in the economic appraisal of health care. NZ Med. J.. 103, 46-8.

8. World Health Organization (1990): Global estimates for health situation - Assessment andprojections. WHO, Geneva.9. U.S. Department of Health and Human Services (1990): Healthy people 2000 - National healthpromotion and disease prevention objectives.

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10. Tinker, A. (1991): Personal communication. World Bank.

11. World Declaration on the survival, protection and development of children and Plan ofAction for implementing the world declaration on the survival, protection and development ofchildren in the 1990s. World Summit for Children, United Nations, New York, 30 September1990.

12. World Health Organization (1989): Progress towards health for all - Second report onmonitoring progress in implementing strategies for health for all. World Health StatisticsQuarterly 42, 1989.

13. Maine, D. (1990): Safe motherhood programmes: options and issues. Centre forPopulation and Family Health, Columbia University, New York.

How much are mothers worth?

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