1. Brucker, Mary C. PhD, CNM, FACNM

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The future of a society is said to be illustrated in how it treats the most vulnerable of its members. Although the author of this statement is in dispute, the concept itself is well accepted. Among emerging nations, maternal child health encompasses the most vulnerable citizens. Since life expectancy tends to be shorter than that in developed countries, the majority of the population in developing countries tends to be young, ranging in ages from being intrauterine to young adolescents. The latter includes the young women who all too frequently become the mothers in the country. Thus, maternal child health tends to be the public health crisis of poor nations.



A population pyramid illustrates the ages of societal members by graphing the number of individuals within an age group. Developing countries most frequently are characterized by an expansive population pyramid or a population that has a broad base because of the high proportion of children accompanied by a rapid population growth, a high death rate, and general short expectancy.1-3 This pattern is commonly found among economically disadvantaged countries. Figure 1 provides an example of a pyramid for Uganda, demonstrating the increased number of youth.4

Figure 1 - Click to enlarge in new windowFigure 1. Population pyramid for Uganda. From US Census Bureau (

In Uganda, approximately half of its population is younger than 15 years.5 Unplanned births in Uganda rose from 29% in 1995 to 38% in 2000-2001, according to a 2006 study by the Guttmacher Institute and Makerere University.6 In addition to Uganda, more than 50 other countries have populations in which greater than 40% are younger than 15 years. All of these countries are in Africa or the Middle East and have high birth rates, as well as high perinatal and maternal morbidity and mortality risks when compared with industrialized nations.



In September 2000, a United Nations Summit culminated in the publication of the Millennium Declaration.7 This document was adopted by approximately 200 nations, signed by more than 140 heads of states and governments and was the basis of 8 goals designed to be achieved by the year 2015. The Millennium Development Goals (MDGs) were written to respond to the world's main development challenges and were subdivided into 21 targets with 60 measurable indicators.8 The goals are found in Table 1 and the targets in Table 2. The latter are regularly monitored for the sake of evaluation.9

Table 2 - Click to enlarge in new windowTable 2. Targets associated with Millennium Development Goal 5
Table 1 - Click to enlarge in new windowTable 1. UN Millennium Development Goals

Promoting improvement of maternal health in any society is a complex issue. Unlike other global challenges such as eradicating polio, no vaccine exists to decrease maternal mortality. Developed countries may desire to use their resources to provide funding to improve care in poorer countries because of humanitarian concerns. Yet a nation with a history of colonialism may view help from developed countries negatively for fear of repeating their previous subordinate relationships. Other countries, both developed and emerging, may have obstacles for sharing wealth, including unnecessary bureaucracy or even corruption.


Although Goal 5 is specific to maternal health, such improvements are impossible without being intertwined with the other goals. Figure 2 is an example of a conceptual framework as created by the United Nations Children's Fund (UNICEF) in an attempt to identify some of the various factors that affect maternal health.10 Poverty and hunger have been well associated with poor pregnancy outcomes. Gender discrimination is an obstacle for women to obtain appropriate healthcare. Education is another influence. Even though 99% of women dying in childbirth are found in emerging countries,11 a woman from any nation who has a secondary education has a marked decrease in maternal and perinatal risk.12 Concomitant conditions such as human immunodeficiency virus and tropical diseases present special considerations for women, especially during pregnancy. Therefore, simply providing funding for "delivery of perinatal healthcare" is insufficient for sustainable improvement in maternal health.

Figure 2 - Click to enlarge in new windowFigure 2. Conceptual framework for maternal and neonatal mortality and morbidity. From UNICEF (

However, Goal 5 does provide a common lexicon for international endeavors as well as a forum for sharing of information and dissemination of information about both successes and failures. Studies are now being published referencing the goal and its benchmarks so that there can be some valid comparisons.13-15



The majority of global initiatives that are being reported in response to MDG 5 are focused on intrapartum events such as management of preeclampsia, postpartum hemorrhage, and infection.16-18 Active management of third stage often is promoted in an attempt to decrease bleeding. Training of traditional birth attendants and midwives is a strategy to increase the numbers of skilled attendants.


Few global strategies appear to target preconceptional health in poorer nations, although this intervention appears well aligned with maternal health.19 A healthy woman is most likely to continue to be healthy during pregnancy and have an uncomplicated birth of a healthy newborn.20 Family planning enables women to become pregnant when they are most likely to have optimal maternal and child outcomes.21


Unlike women in the United States, where many experts note that the rate of cesarean births in excess of 30% is likely unwarranted, women in developing nations often do not have access to such a delivery route when it truly is needed. Therefore, emergency obstetrical care is another critical tactic to improve maternal (and child) health.22



Addressing MDG 5 has mobilized some national groups and promoted collaboration among many others. Multiple nongovernmental organizations that may have been present in sections of the world for decades have been newly rediscovered. A few examples of various groups include the Pakistan National Forum on Women's Health, whose goals include eradication of obstetrical fistulas23 as well as training nursing and midwifery tutors for the provinces in the country.24 Jhpiego, affiliated with Johns Hopkins University, has a new project that focuses on prevention, detection, and treatment of eclampsia in 11 Asian and African countries and $5 million is earmarked for funding as announced at a 2009 meeting of the Clinton Global Initiative.25 Qifang26 is an organization that targets young women in Shannxi, China, and uses social lending and a Web platform to finance their college costs in an effort to have them become community leaders. The Bill and Melinda Gates Foundation is supporting a maternal health task force to improve maternal health worldwide, especially by convening stakeholders in the area in order to decrease duplication, build consensus, and share information.27 The White Ribbon Alliance is a group of nations and others who focus on decreasing maternal mortality in the world.28,29


The US Agency for International Development is a governmental agency that provides funding for international needs, including maternal health and partnering with faith-based groups.30 Although not specific to maternal health, the World Bank provides loans to developing nations at low rates to encourage economic health in a country. UNICEF spends most of its budget on health issues. The Rockefeller Foundation, one of the oldest and best-known philanthropic organizations, is actively involved in projects such as population research. The Project Health Opportunities for People Everywhere is better known as Project Hope and has one of the largest fundings for international care, including women's health. Among faith-based organizations that have partnered with the United Nations Population Fund targeting women's health are World Vision, Islamic Relief, Adventist Development and Relief Agency, and the Salvation Army. A myriad number of other faith-based groups are involved with medical missions worldwide.


When disasters occur in developed nations, the results can be devastating, especially for pregnant women. After Hurricane Katrina struck Louisiana and individuals had to migrate from the area, the very preterm birth rate soared in nearby Alabama.31 However, in emerging nations with low resources and lacking clean water, roads, and other infrastructure, such an event can be devastating. The Nobel Peace Prize-winning Medecins Sans Frontieres (Doctors Without Borders) has teams that include midwives and frequently can be found in areas of natural or manmade devastation.


A call advocating that professional health organizations be actively involved in global maternal health has been articulated.32 Such activities include the International Federation of Obstetrics and Gynecology Save the Mothers Initiative. The American College of Nurse-Midwives has been working globally for more than 3 decades and has specific programs to teach life-saving skills for midwives and obstetrical and neonatal nurses in poor-resource areas and home-based life-saving skills for communities in which home birth is the norm.33 This organization is also assisting with midwifery associations through its Global Outreach department in Africa and the Middle East in an attempt to strengthen them, and therefore, the access and care women in those areas have with skilled providers.34


A recent New York Times bestseller by 2 Pulitzer-winning journalists, Kristoff and WuDunn, has brought the plight of women to a new market of American readers.35 Members of book clubs as well as viewers of television interview programs have learned about the stories of women in other countries. These stories include those of women sold into sex slavery, maternal mortality, and domestic violence in Africa and Asia, as well as tales of hope and promise of education of girls and women. The use of personal stories make issues real to the readers and also are accompanied by lists of programs and groups to which contributions can be made, either monetary or in volunteer time.


The sheer number of groups desiring to improve global maternal health demonstrates the importance of doing so. The health of women has a profound effect on children and families. The phrase "Healthy Women, Healthy World" is found in many publications and Web sites in an attempt to capture the importance of women's health in a user-friendly slogan. Many of the maternal health projects have been undertaken in response to MDG 5 and only preliminary findings exist. Older projects often were initiated in a desire to help and rarely had an evaluation plan associated with them.



Not only do projects help women in emerging countries, but there can be lessons of value for developed nations. Developing nations do not have exclusive rights to vulnerable women or poor maternal health. It may be argued that much of what is being implemented in emerging nations also could be used domestically. Infant mortality rates note that the United States is ranked lower than Cuba, Poland, or Hungary, as noted in Figure 3.36 Women of color are 3 to 4 times as likely as white, non-Hispanic women to die during childbirth (see Fig 4).37 Racial disparities within such a developed country demonstrate a need to improve maternal health within the US borders as well as globally.38

Figure 4 - Click to enlarge in new windowFigure 4. Maternal mortality rates by racial and ethnic group, United States, 2004. Annual number of deaths during pregnancy or within 42 days after delivery per 100 000 live births. From Centers for Disease Control and Prevention, National Center for Health Statistics and Division of Reproductive Health.
Figure 3 - Click to enlarge in new windowFigure 3. Infant mortality rates, selected countries 2005. From Health, United States, 2008 (

Caring for women globally also enables a venue for education of students from North America. Advantages to these learners include exposure to other cultures and management in low-resource areas. Both of these skill sets are valuable to healthcare providers domestically.



Humanitarian efforts of individuals from more prosperous countries to help others in poorer nations are not new. Some actions, especially from the last century, continue to operate such as the hospital established by Albert Schweitzer in Gabon, Africa. Other projects such as the healthcare clinics started by Tom Dooley in mid-century Laos Asia fell victim to war and strife in the country. However, his legacy lives on in other projects he inspired as the United States Peace Corps and various other endeavors as far afield as a large orphanage in rural Bao Lam Vietnam. In the 21st century, the world has flattened, making communication and travel easier than ever before. These positive changes are accompanied by some challenges. Small groups may find themselves with plans to designate adoption of a specific poor area, especially in Africa, Asia, or Latin America. Upon arrival of their team, they find that other well-meaning groups already have started projects. Therefore, partnerships, especially between governments and nongovernmental organizations, are the most likely groups to be successful as they tend to increase communication, decrease duplication, maximize funding, and facilitate sustainability.


Sustainability is a major issue that can be overlooked by small groups focused on immediate needs. As part of sustainability, education of community members to assume roles in nursing, midwifery, or other leadership positions contribute to long-term societal changes and improvement in maternal health. Such education advances the status of women and promotes individuals within the culture.


In summary, maternal health is an integral component of a nation's health and, combined with child health, comprises the most important health issues of a developing country. Safeguarding mothers directly influences generational health. After all, the hand that rocks the cradle rules the world.


Mary C. Brucker, PhD, CNM, FACNM


Baylor University Louise Herrington School of Nursing, Dallas, Texas




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