:
I call the meeting to order.
Pursuant to Standing Order 108(2), we are doing a study on maternal and child health. On April 12, 2010, the Standing Committee on the Status of Women unanimously adopted the following motion to study maternal and child health:
That the committee study maternal and child health following the government's announcement to make maternal and child health a priority at the G-8 in June that Canada will be hosting, as long as this is done before the end of May.
That is why the study is being done now: so that we can complete it before the end of May and have our report ready before the end of May.
We are holding four meetings on this question. The first two meetings will bring together non-governmental organizations and coalitions specializing in developmental issues as well as in maternal and child health.
Today we have three sets of witnesses. We have Dr. Dorothy Shaw, the Canadian spokesperson for Partnership for Maternal, Newborn and Child Health; Janet Hatcher Roberts, executive director of the Canadian Society for International Health; and Jill Wilkinson Sheffield, president of Women Deliver.
I want to welcome you and thank you for taking your time to come and present to this committee and answer some of the questions that everyone is obviously going to be asking you.
Each one of your groups has ten minutes to present. I will give you a two-minute warning so that you will know when you have two minutes left. Then we will have question-and-answer rounds. I think we may be able to do two rounds in this one, but we'll see.
Presentations will be in the same order as you are listed on the agenda. We will begin with Dr. Dorothy Shaw from the Partnership for Maternal, Newborn and Child Health.
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Good afternoon everyone, Madam Chair, Dr. Fry and members of the committee. Thank you for giving me the opportunity to meet with you.
I will speak in English because it will be easier for me to explain these very important things.
[English]
The Partnership for Maternal, Newborn and Child Health is based in Geneva and is a partnership of 300 organizations, including the UN, H-4, non-governmental organizations, health professionals, academics, donors and funding agencies. It's hosted by WHO and its aim over the next six years is that every pregnancy is wanted, every birth safe, and every newborn and child healthy, and that we will save the lives of over ten million women and children by 2015.
The next slide you should have gives you some statistics on the global situation. I'm not going to read them all. I want to bring to your attention that figures on maternal deaths on this slide at 536 are estimated because that's the last UN figure that we have. A paper recently published in The Lancet indicated that figure might be 342,900. That actually would be welcome progress, given all of the efforts that have been done on maternal health, in particular over the last several years. We were expecting to see some progress. The bottom line is that in fact hundreds of thousands of women still die from preventable causes every year.
I hope you are familiar with the millennium development goals. I'm not going to spend time detailing them, except to say that the millennium development goals that have been most off track have been numbers 4 and 5, but particularly goal 5, to improve maternal health. Child mortality has in fact been reduced to less than ten million, which is still a huge number, and that burden is now focused in the neonatal period.
Goal 6, HIV/AIDS, malaria, and other diseases, is obviously very much integrated into what we need to be doing to save the lives of women and children globally.
There is another map, which I hope you have in colour, on the next page. You don't? Okay, I apologize. It's a little difficult to see not in colour. I think essentially what it tells you is that we do have the most recent data now for children. Those will be released further in terms of country-specific profiles at the countdown meeting. Jill Sheffield may say more about that later. We're still waiting for updated information on the maternal health situation, but what those maps show you is that progress has been little in terms of MDG-4 in Africa and insufficient in Asia; and in MDG-5, for the last year that we have data, we are still seeing maternal deaths to be a very common problem in Africa and Asia.
The other thing that is really important to remember is that while you may think those numbers of deaths are not significant in the whole scheme of things in terms of maternal deaths from a numbers perspective, for every woman who dies--and more to the point, when we start getting into what we can do for those where we are providing effective interventions--there are another approximately 20 to 30 women whose lives are seriously compromised with problems such as obstetric fistula. I'd be happy to explain that later.
The next graph, on page 6, shows you in a different way the figures for child mortality for MDG-4 and MDG-5. We know there has been significant success in under-five child mortality in all regions and in many regions by more than 50%. But in sub-Saharan Africa, southern Asia, and Oceania, the regional rates are declining much more slowly. Maternal mortality ratios, which is not the same as the number of women who die--that's deaths per 100,000 live births--are slowly declining across the regions, with few exceptions.
I think what's also important to know is that when we look at the global causes of child deaths and the 8.8 million child deaths every year, we understand why those happen. These are very dependent on the health of the mother. We're again talking about under the age of five. Of those deaths, 41% occur in the neonatal period, which is the first month of life. Of those, we know that the vast majority occur in the first week of life. So this is something that is addressed by providing emergency obstetric newborn care through skilled birth attendants. That's why the focus has been particularly important on that particular group. We know that in terms of those child deaths, 42% are accounted for by pneumonia, diarrhea, and malaria, and under-nutrition contributes to up to about a third of child deaths under five. One of the things that we have learned over time is that there are important variations between regions and countries, and once we have country profile information, that becomes even more evident. So in fact it's very important that countries have their own data, derived ideally by them in order to determine their priorities for action.
When we look at the next slide, it is again from the last countdown figures, looking at the countries with the lowest mortality rates and also at the countries with the highest mortality rates. You will note that of the ten best performers, the last time these figures were released--and we won't have the new figures until June--seven of them have maternal mortality ratios over 100. Anything over 100 is considered high and anything over 500 is considered very high, and anything over 1,000 per 100,000 is extremely high. The solutions and the actions you need to take will differ, depending on the maternal mortality ratios, what is actually responsible for killing women during pregnancy and childbirth.
On page 9, the pie chart looks at why women die during childbirth. We know that postpartum hemorrhage is still the most common killer of women, and unlikely to change based on the updated figures this year. When you look at the obstetric causes of maternal mortality, the next causes after that are hypertension problems, blood pressure problems of pregnancy, and unsafe abortion and infection. When you then look at what we call indirect causes of maternal mortality, that is when you would include problems such as HIV/AIDS, malaria, and cardiac diseases. Altogether, we know that the three leading causes of maternal death are hemorrhage, high blood pressure, and indirect causes, and they account for about 70%.
If you look at the next slide, which is number 10, the coverage failures across the continuum are really quite instructive, and you can see the wide variation in those bars from where the actual bar graph block ends. So you can see that those are opportunities that we have in terms of this Canadian-led initiative, but a G-8 initiative, on maternal and newborn child health to actually make a difference.
Contraceptive prevalence is something where a significant opportunity exists. Skilled attendants at delivery.... We know that, globally, 40% of women deliver without skilled attendants, and in Africa it is higher in many countries. In Ethiopia it is still over 90%. Post-natal exclusive breastfeeding.... You can see where we have in fact many opportunities.
On slide 11, this is a reminder that MDG 5 is also about universal access to reproductive health and that family planning is very significant in terms of meeting the causes of maternal mortality. We know, in fact, the unmet need for family planning, mostly in married women, in the world is 215 million women.
I want to highlight the role of nutrition because this has been quoted in the media as being very significant in saving the lives of women and children. In fact, it's important to recognize that the nutrition of mothers is critical for their children's health--the newborn and child health--because under-nutrition, as you have heard, is implicated in one-third of child mortalities. However, there is no evidence at this point that addressing under-nutrition in women will successfully contribute to eradicating maternal mortality. What kills women, as I said, is hemorrhage.
Interventions needed to save the lives of mothers, newborns, and children are on slide 13. I want to highlight that community engagement is essential. We're talking about a continuum of care that supports nationally led health plans. So the countries need to determine their priorities.
On slide 14 is a demonstration of the platforms, starting with family and community, that are built to deliver integrated maternal, newborn, and child health packages. Through a major funding commitment we can and will save the lives of up to a million women from pregnancy and childbirth complications. You can see the other lives that we will save: 4.5 million newborns, 6.5 million children, and 1.5 stillbirths. And there will be a significant decrease in the global number of unwanted pregnancies and unsafe abortions. We would potentially end the need for family planning. That will take an additional 50 million couples using modern methods of family planning, and 234 million births taking place in facilities.
What will it cost? For the G-8, look at doubling in total bilateral aid, and an appropriate increase in multilateral aid. The funding mechanism is not something the partnership is pronouncing on, except to say that a new funding mechanism would not be recommended.
I want to mention that we have problems at home in our fetal and infant mortality rates. In fact, the infant mortality rate in Canada in 2004 was nearly double in the first nations population, with 9.8 per thousand live births for infants under one month, versus 5.1 for the population as a whole, and over three times the national rate for infants between one month and one year. The problem with mortality and morbidity statistics for the aboriginal Indian and Inuit populations in Canada is that they are very difficult to track. I'd be pleased to explore that a little more with you.
The next slide shows that Canada did make progress when its own economic status was not rosy.
The next slide gives you more detail about the median coverage levels for countdown interventions from this year's report. It indicates that just over half of women have a skilled birth attendant.
The next slide gives you one example--there are many--of how Thailand used midwives, starting with village midwives who were certified, to reduce their maternal mortality.
Accountability is critical. There are some principles articulated on the next slide. All development commitments should be results-based, with specific and measurable objectives. They should be time bound, with clear start and end dates. They should be explicit about whether funding is additional or inclusive of previous commitments. They should also be clear about how much each donor and partner country is contributing.
Page 24 really gives the bottom line: skilled attendance at birth will save mothers and babies.
I think I'll leave it at that.
:
Thank you. It's a great opportunity for the Canadian Society for International Health to be here.
We are a non-government organization committed to the strengthening of health systems. I personally have worked and interacted with ministers of health, education, family and youth, NGOs, and researchers, in over 35 low- and middle-income countries. I've had the privilege of seeing health systems in action and the importance of interaction with other ministries.
I first want to give two points on the political context, and then move into the health systems evidence and add on a bit from Dr. Shaw's comments.
In July 2009 in Italy, as you know, the G-8 heads of government agreed that maternal and child health was one of the world's most pressing global health problems. They committed to accelerating progress on maternal health, including sexual reproduction health care and services and voluntary family planning. They also announced support, as Dr. Shaw mentioned, for building a global consensus on maternal, newborn, and child health as a way to accelerate progress on the MDGs--millennium development goals--for both maternal and child health.
In June 2009 Canada co-sponsored a landmark resolution at the UN Human Rights Council recognizing maternal mortality and morbidity as a pressing human rights concern.
I'll talk a bit more on the health systems evidence. Most maternal deaths are easily preventable, as we said. We've seen this wonderful progress in Canada, although we do have some inequities. The gap between rich and poor countries is shockingly wide. In Canada, for example, the lifetime risk of maternal death is one in 11,000. In Ethiopia, the risk is one in 27. In Angola and Liberia, the risk is one in 12; and in Niger, it's one in seven.
Of the 10 million women who have died in pregnancy and childbirth since 1990, three-quarters of the deaths were preventable, primarily where they occur in Africa and South Asia. Millions of other women have been left with crippling injuries or illnesses as a result of poor care during childbirth.
A new study released in March 2010 by the United Nations Population Fund, UNFPA, and the Guttmacher Institute estimates that 70% of the world's maternal deaths could be prevented for $13 billion. That's about $4.50 per person, per year. That's not a lot of money.
Dr. Shaw mentioned some of the care gaps. Of the 123 million women in the developing world who gave birth in a health care facility and needed care, 62 million received it. Of the 5.5 million women who needed care for hemorrhage or bleeding, 1.4 million received it. You can see these huge gaps. Of the 7.6 women who needed care for obstructed labour--that means when the baby is not coming out very well--1.8 received it. There are huge care gaps.
There are 215 million who would like to delay or avoid child bearing and do not have access to modern contraception. A dramatic improvement in access to family planning, including contraception, would sharply reduce the number of unintended and unplanned pregnancies. That in itself means fewer pregnancy-related deaths and complications. Evidence shows that access to family planning alone could prevent as many as one in every three maternal deaths by allowing women to delay motherhood.
It's not just what we need to deliver but how we need to deliver it. And how we need to deliver it is through a sustainable and well-funded health system. That's not just the care part, the services and programs you've heard about, which are very, very important, but a whole health system.
There is a picture here of what a health system is--you will all receive copies of this. The services and treatment and programs are the health care system, but a health system has many elements. One is a vision for equity and a fair distribution of resources coupled with leadership and sustainability. It also has to do with a fair access, not equal access. We'll never have equal access, but we can have a more fair distribution and availability of services for health care.
We also need health information systems. That is often forgotten about, but unless we have funding for health information systems when we also fund intervention programs for maternal health, we will never know how well we are doing. So we need to make sure that is integrated within the health system, because that gives evidence for policy, but it also gives evidence for how well we are doing in terms of quality of care.
A great gap in many low-income countries is the ability to plan, the ability to say where these resources should go. Most countries have a decentralized social system in education and health. They were decentralized almost overnight as a result of World Bank demands and their structural adjustment, and they have very little capacity for planning. Therefore, the decisions about where the money goes are left in the hands of people who don't have data, who don't have capacity, and thus the resource allocation is not evidence-based. Of course, we need well-trained professionals--nurses, doctors, midwives, community health workers--to be in the right place at the right time doing the right thing, but we also need to promote a continuum of care throughout: a primary health care system that delivers a large part of maternal and child health, well baby care, well pregnant care, and we need emergency obstetrical care. That is essential. Without a primary health care system--if that gets gutted--we don't have a continuum of care. That's the access point for mothers and for their children. It allows for anything that needs to be dealt with at a specialist level to be picked up.
Sub-Saharan Africa faces the greatest challenge. While it has 11% of the world's population and 24% of the global burden of disease, it has only 3% of health workers. In addition to the care part of the system and the health information, it's also important that there be public participation in health care decision planning, as we have here in Canada. People get involved and make their views known. Non-governmental organizations need to be funded to build that capacity for communities so they can start to understand what they need and where and how they need it.
Finally, there needs to be a transparent and accountable public system. Most countries have a publicly funded system, and they often have a privately funded system. Doctors sometimes work in the mornings in the public system, and in the afternoon they go to the private system. So if you go to a clinic in the afternoon in many of these countries, there is nobody there. That is because the doctors are off in the private system, because they have probably not been well paid in the publicly funded system. This shows the need for a well-funded public system.
There are two pillars that really support a health system. One is the determinants of health, and you have probably heard about those: poverty, education, peace, gender. These are things that make us healthy. If we have a peaceful situation, if we don't have an environmentally challenged system, if we are not poor, if we are well educated, if we have jobs, we tend to be healthier. You will get copies of these maps that show the absolute significant and critical inequities of the distribution of these determinants of health. If you look at education, if you look at poverty and wealth, the maldistribution is huge.
Finally, we have to look at the policies that have an impact on health. It's not just the ministry of health. It is the ministry of transportation. It's the ministry of environment. It's trade. It's labour. It's human rights. If we work with the transportation sector to look at where the roads would go, we could hook up with the primary care systems and the delivery of good care. If we know that the environment and environmental policy are health promoting, we have a better chance at improving our health, so we have to look at all of those policies in terms of health, but more particularly in terms of maternal and child health.
Finally, Canada has played a leadership role in promoting good governance and accountability across many sectors, including health, and we feel it could take a leadership position in supporting this as it relates to maternal and child health.
I'm sorry that you didn't get the slides, but I'm sure you will get them later, and you will be able to see them in colour as well. I'm sure that's the case for yours too, Dr. Shaw.
Thank you.
:
Thank you, Madam Chair and committee members, for inviting me here this afternoon to talk about the fact that women do deliver. They deliver babies, and they die in large numbers. They also deliver a lot of other things. They are major benefits to our social and economic fabric of life around the world.
I am Jill Wilkinson Sheffield and I am the president of Women Deliver. We're a global maternal health advocacy organization. We use all the data that Dr. Shaw has shared with you, and I'm so pleased to be speaking after Dr. Shaw, so I can save on the numbers.
It's a really important time for the women in the world, and frankly a momentous time for Canada. Women are the economic heart of the developing world, and they really need to know that their lives, their health, and their rights matter. Perhaps just as importantly, they need the funding committed to make that happen.
I want first to thank the Canadian government, which for decades has worked steadfastly toward improving the health of mothers and their newborns and children in developing countries. In my 30 years in the maternal health field--and in the reproductive health field, more largely--my fellow advocates and I have known Canada as a true ally and we have appreciated your strong leadership and your commitment. And we're counting on it now, as June approaches.
As you may know from the news, the most recent studies on maternal mortality demonstrate that we are making progress. This tells us that investments are paying off, and it tells us that there are solutions at hand that we can employ more broadly.
We have only five years left to achieve the millennium development goals. You know that MDG 5 is to improve maternal health. Its target is to reduce maternal mortality by three-quarters in these remaining five years. Unfortunately, so far this is the goal that has made the least progress. It has also had the least investment. And if women are the heart of our families and our economies, it's time to change that.
Canada has an unparalleled opportunity to lead the promise of progress on this issue with its legacy initiative on maternal, newborn, and child health, to be introduced at the G-8 and G-20 summits in June. And yet as Canada seeks to shape its legacy, I urge you not to forget your past legacy. It's building on great success.
In 1994 in Cairo, Canada joined 178 other countries in a global consensus on the importance of addressing the health and rights of women in a comprehensive framework. That was the United Nations International Conference on Population and Development. And since that time Canada has not erred from its commitments. Now is not the time to do it either.
In 1974, even longer ago, Canada was at the table in Bucharest when it was agreed by the nations of the world that individuals and couples had the right to plan the number and spacing of their children, and that it was the responsibility of governments to ensure this happened.
Fortunately, to address maternal mortality and to achieve MDG 5, we really don't need the discovery of a miracle drug or an expensive medical breakthrough. We have low-cost solutions now. We know what works and we know it now. You've heard it already, just before my turn.
Women need access to family planning programs and modern contraceptives. And they need access to skilled care before, during, and after childbirth, especially access to emergency obstetric care. And we don't know when these emergencies will arise; that's one of the problems. Women also need access to safe abortion services when and where they are legal.
These solutions aren't rocket science, but they do save lives and they present enormous economic, social, and health benefits. Hundreds of thousands of women die each year in pregnancy or childbirth. We now know that the world loses $15 billion in lost productivity because of these deaths. I'm not sure anyone feels that this sum can afford to be lost--lost lives or lost productivity.
So while I wouldn't claim that maternal health is a simple issue to address, if we are to advance as a global community into a millennium of stability, prosperity, and dignity, it's a very necessary issue for us to address. Global consensus has been achieved before; we can do it again. In fact, we have to do it again for the sake of the women and the girls and our futures worldwide. We know what it costs to do this. It's an additional $12 billion a year, and that's not a lot in the scheme of things.
Over the past decade, since the global efforts, there have been setbacks and stagnation. We also know that we've made enormous progress. There are low-resource countries that have made dramatic changes in the situation of health for mothers and girls. Rwanda, Bangladesh, Honduras--the mark that all of these countries have in common is political will. They simply decided it had to be done and they are doing it, just as we know that not to decide is also to decide.
There are few times in your careers as parliamentarians that a problem and terrible injustice that has brought suffering to millions of women and their families can actually be solved. This is our moment to make this happen. We can do it. We absolutely have to do it. It's over to you and up to you, and civil society is ready to help in any way we can.
Thank you again for the invitation.
Thailand, as I said, is just one example. We could give you Sri Lanka, Malaysia, and in fact Brazil. Brazil is probably the most recent example where they have managed to reduce the under-five death rate and they've now managed to get free primary health care for everyone. All Brazilians have access to skilled attendants at birth. They now have to work on other issues, such as the quality of the care that is being delivered, but they do now have that. So that's been a huge undertaking, because we often still see inequities in poor countries between the richest and the poorest quintiles in both maternal and child health. Brazil deserves a great deal of credit for that.
So I think that Thailand's success story, mirrored by others--and Janet and Jill probably can also answer this--is interesting in many ways, because it really does involve the community. You need to involve the community. Often we have traditional birth attendants in villages who attend mothers if they don't give birth alone, and those were substituted by certified village midwives.
Now, I don't have the specifics of how long they would train for in Thailand. There are some other countries where midwives are being trained for less than the four years that we train our midwives here in Canada, and we can debate the merits of that. But six months is a bare minimum for training. They are trained close to the village and go back to the village.
What happens is as you begin the training, you scale it up over time. You can see in this graph what happens when you start training and then when you scale it up.
In fact, what's really fascinating.... I do have a slide that's not in this set that takes you back to the Taj Mahal, which is a monument to a woman who died of a postpartum hemorrhage after giving birth to her fifteenth child. At that time Sweden also had a high maternal mortality rate, and the queen of Sweden decided that she was going to start a midwifery training school. The rest is history in terms of what happened in Sweden with maternal mortality.
Yet in India until very recently--the most recent figures for India are showing progress--the most common cause of death, as with the rest of the world's women, is still postpartum hemorrhage.
:
Thank you, Madam Chair.
Thank you, ladies, very much for being here. I found your presentations very enlightening and very educational.
I want to pick up in just a minute on an issue you spoke about, Ms. Sheffield.
But Dr. Shaw, you spoke specifically about countries being willing countries, saying that we need to work with countries that are prepared to make changes and work with us on issues to build the capacity they need to build health systems.
I was very privileged last year, Ms. Sheffield, to visit Bangladesh. This year I happened to be in Zambia and Botswana and had some observations there too. Bangladesh is a very needy country, but one that has recognized some of the problems it faces and is prepared to work on them.
My comment is that what I also observed was that the day that a girl starts her period, the day she begins menstruation, is the day she becomes, in their culture, of marriageable age. We are dealing with culture shift in many ways and we know that culture shift changes at glacial speed. So we have issues there that we need to work with.
What I saw in Bangladesh was the introduction of what they call a Shasthya Shebika in the villages, whereby they have a woman who is trained in basic health initiatives to be the first responder, as it were. She is given some very elementary training in midwifery. What she is really trained for, though, is tuberculosis identification and giving access to medications, which the state is working on providing. That was very helpful.
I also had the opportunity to visit a maternal health centre, if I may call it that, in the slums of Dhaka, where birthing units are available. They are elementary, by all means.
If girls are leaving school at the age of 13 because they are now of marriageable age or eligibility, how do we go about changing the attitude to keep girls in school? We know that education is what's going to change. I watched them having to teach women over and over again how to wash their hands, because they don't know to wash their hands after they have been to the sanitation facilities, or lack thereof. And clean water is absolutely non-existent there. We know this is transferring disease to young children.
When we say that we're prepared to work with the vertical issues, how do we change this and help create educational opportunities for girls, because we know they're going to be the ones who take this forward?
Could either of you comment on that?
:
I must say that as the chair my comment is simply that we have asked a minister who is particularly responsible to this committee and we have not even heard from her. I have not had a simple response of any kind--a yes, no, don't bother me, or anything. I've just had nothing.
had said she couldn't come on the dates that we had suggested, and we have since sent back to ask her if she could come on May 26, which would be before the end of May. We have not heard a response to that.
We're now asking two ministers to come. I would just like to comment that in the past, when we were looking at other issues, such as EI, we had asked the minister of HRSDC to come. We had asked the minister of the Treasury Board to come with regard to pay equity. Ministers do not have to appear before a committee. I guess that's their executive prerogative not to do so. However, as chair of the committee, I might suggest that when a committee asks for information and asks for clarification because we need to understand the issue better, I really think.... I have been here for 17 years, and it's the first time I have seen ministers completely not responding. It's not just not coming, but it's not responding to chairs of committees and committees who request their presence. That concerns me a little bit. It is something I think Ms. Simson is alluding to.
I know the parliamentary secretary can only do what the parliamentary secretary can do, which is ask. If the parliamentary secretary doesn't get an answer, she's being considered to be not as important as the committee is either. A committee of the House is an important body. You've heard the Speaker speak to this issue. A committee of the House is here, in a non-partisan way, to gather information, to understand the issues, and to speak to them, to report on them, to make recommendations, if they believe that Parliament does not have the answers it requires. That's how you get answers, through committees. So I am concerned, and I want the concern to be on the record in this instance.
I sent a third letter to the ministers last week, personally sending them the motion, reminding them that this has to be done before the end of June, and we have not heard anything back. Not even to acknowledge is not a good thing, I think. It's not particularly respectful of committees.
That's speaking to the issue of Ms. Simson's question.
Now, we have another question we need to ask. Ms. Neville had put forward a motion in the last meeting that the committee hold a special meeting to examine the manner in which funding is distributed by Status of Women Canada, etc. She had said that this was a special meeting. The point is, if it's a special meeting, I asked everyone to think about it, because it means it is outside of the two meetings a week that we have. Have you got a date, as a committee, that we will stay one evening and get this done? We have all passed this motion--it was passed by the committee--to hold a special meeting. “Special” means outside the normal meetings. It's for one meeting. We've asked for this to come to the clerk and the analyst, but we have not had a response from the committee on this. We need to make that decision.
Ms. Neville.