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Birth Situation Room:
State of the World


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The reports in this area of the Birth Situation Room are to inform you of how birth is doing around the world in a broader context than a specific country. For example, Robin Lim’s report about poverty and Marsden Wagner’s articles about dangerous technology have been placed here. A report about a region of the world belongs here as well. —Jan Tritten


• The State of the World’s Midwifery 2011
• World Health Report 2008
• Changing Childbirth: The Latin American Example—Robbie Davis-Floyd  [December 2007]
• Effect of Poverty on Birth—Robin Lim  [July 2006]
• Ultrasound: More Harm than Good?—Marsden Wagner, MD  [June 1999]
• Technology in Birth: First Do No Harm—Marsden Wagner, MD  [2000]
• Cytotec Induction and Off-Label Use—Marsden Wagner, MD  [September 2003]
• Ultrasound: Weighing the Propaganda Against the Facts—Beverley Lawrence Beech  [September 1999]

The State of the World’s Midwifery 2011
Foreword by UN Secretary-General

[View individual country data and profiles]

[The full report, with many helpful charts and graphs, is available here.]

This report comes at a propitious moment in the international campaign for women’s advancement. The recent establishment of the dynamic new agency UN Women, as well as the launch of the Global Strategy for Women’s and Children’s Health, combine to offer hope for greater progress in the coming years.

Nowhere is this more urgently needed than in preventing one of the greatest tragedies of our time: the needless death and injury each year of millions of poor and marginalized women and children worldwide. Of the eight Millennium Development Goals, the two specifically concerned with improving the health of women and children are the furthest from being achieved.

This is not a matter of statistics. The woman who perishes from hemorrhaging during childbirth or the infant who dies during a complicated birth each has a name and a family who love and cherish them. Beyond individual tragedy, these losses carry untold social and economic repercussions for society.

We know what is needed to make pregnancy and delivery safe: access to health services, including skilled birth attendants and a functioning health care facility. We also know it is possible to mobilize the leadership and action needed to provide these services to every expecting woman and her baby.

At the launch of the Global Strategy, numerous developing countries demonstrated great political will—backed by new commitments—to scale-up the number of skilled birth attendants and provide the midwifery services that women need throughout their reproductive years.

The State of the World’s Midwifery 2011—the first of its kind—takes stock of the practice in 58 countries. Collectively, they represent 91 percent of global maternal deaths. Using fresh data, information and analysis, the report identifies common challenges within and among countries while highlighting promising approaches to strengthen midwifery services around the world.

The report focuses on the critical early period when deaths can be averted. It is an important companion to other efforts aimed at rigorously measuring action and results, including the Global Strategy and the report of the Commission on Information and Accountability for Women’s and Children’s Health.

Ensuring that every woman and her newborn have access to quality midwifery services demands that we take bold steps to build on what we have achieved so far across communities, countries, regions and the world. Our responsibility is clear: we must safeguard each woman and child so they may live to their full potential. The results will reverberate far beyond the lives of those directly affected, fostering a better world for all.

Ban Ki-moon,
Secretary-General of the United Nations

World Health Report 2008

The World Health Report 2008 critically assessed the way that health care is organized, financed, and delivered in rich and poor countries around the world. The World Health Organization (WHO) report documents a number of failures and shortcomings that have left the health status of different populations, both within and between countries, dangerously out of balance.

Differences in life expectancy between the richest and poorest countries now exceed 40 years. Of the estimated 136 million women who will give birth this year, around 58 million will receive no medical assistance whatsoever during childbirth and the postpartum period, endangering their lives and those of their infants. Globally, annual government expenditure on health varies from as little as US $20 per person to well over US $6000. For 5.6 billion people in low- and middle-income countries, more than half of all health care expenditure is through out-of-pocket payments. With the costs of health care rising and systems for financial protection in disarray, personal expenditures on health now push more than 100 million people below the poverty line each year. Vast differences in health occur within countries and sometimes within individual cities. In Nairobi, for example, the under-five mortality rate is below 15 per 1000 in the high-income area. In a slum in the same city, the rate is 254 per 1000. "High maternal, infant, and under-five mortality often indicates lack of access to basic services such as clean water and sanitation, immunizations and proper nutrition," said Ann M. Veneman, UNICEF Executive Director.

To steer health systems towards better performance, the report calls for a return to primary health care, a holistic approach to health care formally launched 30 years ago. When countries at the same level of economic development are compared, those where health care is organized around the tenets of primary health care produce a higher level of health for the same investment.

In far too many cases, people who are well-off and generally healthier have the best access to the best care, while the poor are left to fend for themselves. Health care is often delivered according to a model that concentrates on diseases, high technology, and specialist care, with health viewed as a product of biomedical interventions and the power of prevention largely ignored. Specialists may perform tasks that are better managed by general practitioners, family doctors, or nurses. This contributes to inefficiency, restricts access, and deprives patients of opportunities for comprehensive care. Above all, health care is failing to respond to rising social expectations for health care that is people-centred, fair, affordable and efficient.

A primary health care approach, when properly implemented, protects against many of these problems. It promotes a holistic approach to health that makes prevention equally important as cure in a continuum of care that extends throughout the lifespan. As part of this holistic approach, it works to influence fundamental determinants of health that arise in multiple non-health sectors, offering an upstream attack on threats to health. Primary health care brings balance back to health care, and puts families and communities at the hub of the health system. With an emphasis on local ownership, it honours the resilience and ingenuity of the human spirit and makes space for solutions created by communities, owned by them, and sustained by them.

— World Health Report 2008, WHO, Oct 2008. http://www.who.int/whr/2008/en/index.html

Effect of Poverty on Birth [July 2006]

One mom births perfectly, a healthy baby boy. Another suffers a stroke in childbirth, and baby’s Apgars are 3 and after 20 minutes, 7. Why was the second mom’s outcome, same day, on the island of Bali, so different? Answer: poverty. The second mom was too poor to eat well. We must change the agricultural agenda of the world’s powers so that we can feed our expectant mothers. This must happen for there to be hope for future generations. It will take every individual living in the heart of compassion, as mothers live and serve, to save this world.

Robin Lim, CPM—Indonesia