WHO NEWS
Fighting the 'silent epidemic'
An estimated 11 million children under five years and more than half a million mothers globally are likely to die this year due largely to preventable causes. As Assistant Director-General of the Family and Community Health cluster at WHO, Joy Phumaphi’s task is to raise the profile of perhaps one of most neglected areas of public health. Phumaphi told the Bulletin she hopes the World health report 2005: Make every mother and child count, to be published on 7 April, and the recent appointment of Ethiopian fashion model Liya Kebede as WHO's Goodwill Ambassador will spur efforts to do more for maternal and child health.
Q: What simple, cost-effective treatments if introduced in the world's poorest countries could substantially improve the survival chances of mothers when they give birth?
A: Access to professional care in the pregnancy, childbirth and postpartum periods is key to addressing the major causes of maternal mortality. If comprehensive services were made available, you could save most of the lives of the mothers who die. Often, women who haemorrhage badly need a blood transfusion and often don't have access to a hospital. Obstructed labour is also a problem and facilities that can provide caesarian section are often not accessible. Many women deliver in unsafe conditions with traditional birth attendants who do not have the skills needed to help when something goes wrong. In addition, sepsis or infection can occur, so making antibiotics available to health services would also save lives. Women need skilled antenatal care to identify whether there is a need for delivery in a health facility. Antenatal care providers can show women how to look after themselves during pregnancy and deal with any serious health problems that may arise.
Q: What other factors can contribute to the ill-health of mothers and neonates?
A: There are aggravating conditions where there is a high prevalence of HIV/AIDS, or malaria. That's why it's so important for services for the prevention of mother-to-child transmission of HIV to be made available and for women to be given a prophylaxis for malaria during pregnancy and assisted to have a balanced diet to be as healthy as possible during pregnancy.
Q: What simple interventions could save newborn infants' lives?
A: If comprehensive health services with skilled professionals are accessible during pregnancy, birth and afterwards, then a very large proportion of newborn lives can also be saved. As newborn mortality is a substantial part of overall child mortality, it needs to be tackled.
Q: Have you given your cluster a new direction since you arrived at WHO in August 2003?
A: The cluster deals with primary health-care programmes in the most basic developing country health systems. The tools, guidelines, norms and standards that have been developed over the years are very good. But now we need to increase support to help countries translate this into policies, strategies and practices. We have created a new department: Making Pregnancy Safer and strengthened an existing one, Gender, Women and Health. This shift in focus should put us in a better position to attain the Millennium Development Goals on maternal and child health.
Q: What concrete progress in improving maternal and infant survival do you expect from World Health Day on 7 April, when the world health report devoted to the subject will be launched?
A: Every year we lose about 11 million under-fives, mainly to preventable causes. Four million of these under-fives die in the first week of life. An additional 3.3 million die during or before birth. Every year about 529 000 women die during pregnancy, childbirth or shortly afterwards. These are alarming statistics, it's a huge loss of life. But the scale of the problem and the scale of neglect in this area are not yet apparent to the global community. It is a silent epidemic. We hope to give a voice to the 11 million children and half a million women we are losing every year. These women and children are not dying in a natural disaster, like a tsunami. It is a disaster which the adult world can prevent because we have the solutions.
Q: And what are those solutions?
A: Children die from pneumonia and from sepsis, but we have the antibiotics to treat these. Many are still dying of diarrhoeal disease, but oral rehydration salts (ORS) are an effective treatment, and were developed decades ago. We know that breastfeeding is the best form of nutrition for babies and that it also protects them from illness. We know that kangaroo mother care, when the baby is strapped to the mother, is the best way to care for small or premature babies. We have interventions, like the Integrated Management of Childhood Illnesses. We have evidence-based solutions which the World Health Day and the World health report should publicize to the global community. However, to make these solutions work for women and babies we need skilled professionals with the drugs, supplies and equipment to implement them.
Q: Which countries have the highest mortality rates for mothers, infants and children?
A: The Democratic Republic of Congo, Ethiopia and Nigeria have the highest death rates in Africa for mothers and children. Every year, 136 000 maternal and more than 1.1 million newborn deaths occur in India alone. Some countries which dealt consistently with these challenges and made progress in the 1990s have now regressed due to HIV/AIDS and depressed economies, such as Malawi, Mozambique, Zambia and Zimbabwe. Middle-income countries, such as Botswana, Namibia and South Africa are also experiencing setbacks and need mainly guidance on policy-making.
Q: A commentary in the Lancet in December last year criticized the 2005 World health report on maternal and child health for inadequate consultation of stakeholders. Is this fair?
A: We started by consulting the regions of WHO and countries, as well as a broad array of global stakeholders and child experts. Unfortunately, at the time the article came out in the Lancet we were still in the process and some of the consultation meetings had not yet taken place. We never had a World health report that enjoyed this level of consultation, so the criticism was a bit premature.
Q: The health of mothers, infants and children is particularly vulnerable in conflict situations and emergencies, how are you tackling this problem?
A: Often women and children are the first to suffer when the access to health-care services is disrupted. We work with WHO's Health Action in Crisis (HAC) when they support and set up emergency medical care facilities. Usually these address communicable diseases and injuries and, if we are lucky, mental health issues. In order for them to save mothers and children, they must include routine antenatal care, skilled care at every birth with back-up services for women with complications. Care must continue after delivery for the mother and infant and appropriate service links must be made with child care and family planning services. These services must be available from day one.
Q: More than 500 000 women are dying in childbirth every year, has this situation got worse in the last 50 years, or was it even worse before?
A: In the last 50 years it has definitely improved but it has more or less remained stagnant in the past 10 years because the issue is not being given enough attention. Recently, the Kenyan parliament was given statistics on the number of women dying in childbirth in their country and they were shocked. They did not understand why so many women should still be dying in childbirth. This came to light in Kenya when we launched a training programme called Beyond the Numbers, which helps countries document the causes of maternal death, count the women who die in childbirth and establish ways to bring the right solutions to communities. Often the policy-makers are not aware of the numbers because a lot of women deliver at home, die at home and are not being counted. 
