Rights On the Alameda
November 19, 2015
A focus on quality of care, service integration, and equity at the Global Maternal Newborn Health Conference in Mexico City
Last month I was in Mexico City to attend the first Global Maternal Newborn Health Conference, which ran from October 18 to 21. The theme of the meeting, hosted by Mexico’s Secretaría de Salud, and co-organized by the Maternal Health Task Force, Save the Children, and USAID’s Maternal and Child Survival Program (MCSP), was “reaching every mother and newborn with quality care.” Over three and a half days more than 1,000 participants from 75 countries and more than 400 organizations focused on several key issues at the heart improving maternal-newborn health services globally: ensuring care is patient-focused; integrating programs to better serve the needs of mothers and babies; and extending innovative health services to the poorest and most socially vulnerable mothers and babies. Speakers acknowledged the importance of bringing the maternal and neonatal health communities together -- a gathering that many said had not taken place in recent history -- and emphasized that while the world has made progress since 1990 in reducing maternal and child mortality, significant gaps remain. Through a series of high-level plenaries, as well as smaller panels and side events, participants agreed that the new Sustainable Development Goals' (SDGs) focus on equity offers an opportunity to address both the "unfinished" MDG maternal, neonatal and child health agenda and anticipate the needs of today's girls and adolescents, many of whom will be tomorrow's mothers.
Discussions at the conference, described as the first big international meeting to take place since the September approval of the SDGs at the United Nations General Assembly, centered on global themes; however, there were several panels that analyzed recent successes in improving maternal and child health in Mexico, itself. A middle-income country and member of the Organization for Economic Cooperation and Development (OECD), Mexico has had federally-supported family planning programs in place for several decades; its total fertility rate has dropped from an average of 7.2 children per woman in the 1960s to a current rate of 2.2, with an estimated 88% demand for family planning satisfied. Thanks to insurance programs that provide services to public sector workers and private sector employees, as well as programs run by the health ministry for those not formally employed, Mexico has achieved universal health coverage. Regardless of which entity actually provides her health insurance, a woman in Mexico can seek maternal care services in any facility. At least 98% of women attend at least one antenatal care visit with a health care provider, and 96% of women deliver their babies with a skilled attendant present. Mexico has one of the oldest and most distinguished public institutes for perinatology in the Latin America and Caribbean region.
Yet, like so many countries around the world, Mexico continues to face challenges when it comes to reaching the most vulnerable mothers and babies with quality health care. Mexico is not expected to reach its MDG 5 target of reducing maternal deaths 3/4 from 88 per 100,000 live births in 1990 to 22 per 100,000 by the end of 2015. Hemorrhage and hypertension, as well as complications from diabetes and other chronic conditions, are the leading causes of maternal death in Mexico. As overall child mortality has decreased, newborn deaths now account for 53% of all deaths among children under the age of five. Mothers and children living in the most impoverished areas of the country -- the mountainous southeastern states of Oaxaca, Guerrero, and Chiapas, which also have high concentrations of indigenous populations -- face the greatest challenges in accessing quality health care services.
A new book presented at the conference, 25 años de buenas prácticas para disminuir la mortalidad materna en México spotlighted the role that academic associations and civil society have played in advocating for a rights-based approach in ensuring quality health care is available to socially marginal women. The editors, who include midwives, obstetricians, journalists, and social scientists, credit the formation of the Comité Promotor por una Maternidad Segura en Mexico (CPMSM) in 1993 with bringing government, academia and civil society together to better monitor women's access to quality maternal care services. The chapters identify six factors - citizen engagement in processes to improve maternal health; independent monitoring of public programs; an intercultural focus on maternal health services; strengthening strategic actors in the policymaking arena; an emphasis on strengthening the training and professionalization of midwives; and the evolution of information systems for health -- that have facilitated a greater emphasis on reducing maternal mortality in Mexico over the past three decades. Through careful case studies and featured interviews with women across Mexico, the authors emphasize the importance of using a human rights framework to prioritize interventions to protect Mexico's poorest mothers and their newborns from preventable early death.
Arriving every day at the conference venue, the Hilton Reforma on Mexico City’s Avenida Juárez, I was reminded of a time when the rights of the most impoverished mothers and their children were all but ignored within Mexico's public health services. Across the beautiful Alameda Park from the Hilton sits a colonial-era building once known as the Hospital Morelos, the city’s public hospital for women diagnosed with syphilis and other sexually transmitted infections. (The building is now the Franz Meyer Museum and holds Latin America's largest collection of decorative arts). As I approached the Hilton each morning and saw the old hospital, I recalled that while carrying out archival research for a book on public health in Mexico City after the 1910 Revolution, I uncovered letters to officials from patients who identified themselves as “mujeres públicas,” or sex workers, and decried the deplorable conditions at the facility. Following a decade of rural violence and social upheaval, migrants flooded to Mexico City in the 1920s; lacking education, skills, or families to support them, thousands of the young women within that migrant stream became involved in the city's sex trade and were infected by clients with syphilis, gonorrhea and other deadly and disfiguring diseases. Interned in the hospital against their will, they complained that they were frequently compelled to sleep two or more to a bed and were forbidden to have their children stay with – or even visit -- them as they languished on the wards for months at a time to undergo painful treatments of dubious efficacy. Yet in letters to doctors, legislators, and President Plutarco Elías Calles, himself, the women asserted their dignity and right to be treated as “decent people,” reminding officials that even if they were engaged in what they acknowledged might be viewed as undesirable (albeit not illegal) work, they were nevertheless caring mothers who loved their children and worried about their welfare.
Three plenary discussions at the Global Maternal Newborn Health Conference focused participants' attention on themes of quality of care, program integration, the right to health, and equity. Like the sick women in 1920s Mexico City, the plenary speakers emphasized patients' dignity -- and the importance of their care being evidence-based, reliable, respectful, and acceptable to them -- as they debated the definition of quality care for mothers and newborns during the session on the first afternoon. The plenary on integration that took place Tuesday morning similarly highlighted the importance of placing mothers and babies at the heart of any service scheme, with speakers noting that program integration can be costlier, more time-consuming, and less convenient for health providers, but if integrating programs benefits patients then it should be a priority. In the final plenary session, speakers focused on equity and rights, noting that failing to ensure mothers access to quality health services, including sexual and reproductive health services, effectively denies their agency as political actors; if women are not healthy, they can't act effectively to advance their own interests, much less the interests of their children.
By the close of the conference, I found myself inspired by the many achievements in improving the quality of maternal and newborn care that were reported and hopeful that the lessons gleaned from diverse fields and country contexts will be effectively shared and applied in new settings. The message that promoting sustainable quality health care for mothers and babies means thinking about how to improve MNCH programs in relation to other key SDG goals, including access to modern energy supplies, ecosystem conservation, and availability of water and sanitation services, also resonated for me. I agreed with many attendees who commented in the final session that if there is to be a second Global Maternal Newborn Health Conference, it will be essential to bring the politicians, decision-makers, and finance officials to the gathering and to ensure that they hear, first-hand, from mothers who can share their experiences and express their views.
Unlike the officials in 1920s Mexico who, despite the mandate of social revolution, nevertheless ignored poor patients' demands for respect, rights, and better health care, those at the October meetings understand that it will be difficult to reach the SDGs' targets for reducing maternal and neonatal mortality by 2030 without the active engagement of mothers, themselves. Moving that conversation between vulnerable mothers and public officials beyond Mexico City's Alameda and into dispensaries, clinics and hospitals around the world is the right thing to do.