ALL-PARTY POPULATION, DEVELOPMENT

AND REPRODUCTIVE HEALTHGROUP

MINUTES OF PROCEEDINGS

at a

PARLIAMENTARY HEARING

on

MATERNAL MORBIDITY

held in

Room 21,Palace of Westminster

on

Monday 8 December 2008

Morning Session

Panellists:

Baroness Tonge (Chairman)

Chris McCaffertyMP

Lord Rea

Sandra Gidley MP

Lord Patel

Baroness Thomas of Walliswood

Ros Davies

Amy Kesterton

Anne Quesney

Belinda Tima

Jennifer Woodside

Ann Mette Kjaerby

(From the Shorthand Notes of:

W B GURNEY & SONS LLP,

Hope House,

45 Great Peter Street,

London SW1P 3LT)

Witnesses:DR JOHN KELLY, Obstetrician; DR TONY FALCONER, Vice President, and DR NYNKE VAN DEN BROEK, Director International Office, Liverpool, RCOG International Office; and MS FRANCES DAY-STIRK, Director of Learning, Research and Practice Development, RCM, gave evidence.

CHAIRMAN: Thank you all very much for coming and for being so prompt because we really have got a lot of work to cover in the time. The form for this session, which is going to last an hour and a half, is that I am going to ask each of the people who have submitted written submissions – that means the Royal College of Obstetricians and Gynaecologists are counted as one for this purpose – to give not more than 100 words just as a brief resumé of your case on this subject, and then you will be taking questions from the Panel. We are a range of politicians from the Commons and the Lords and people from NGOs dealing with women’s health.

This inquiry is into maternal morbidity and as Chairman I have to say that this subject interests me. We always hear the emphasis and the Millennium Development Goal emphasis on maternal mortality but I do not think this covers the whole problem, especially nowadays when we are talking all the time and hearing people talk of billions and trillions and these huge numbers are being kicked around the world and you say half a million women die every year in childbirth – so what? We have to add to that half million the millions of women who are permanently disabled and have their lives ruined by childbirth every year. This inquiry is to strengthen the argument for women’s health and reproductive health in particular. We are hoping to get some really good facts and some interesting stuff out of all of you which will forward the cause of women’s health worldwide.

My first question, just to start you off, will come after you have given us your 100 words, so it is over to you. We will start with Dr John Kelly.

DR KELLY: Thank you, my Lady Chairman. I am very grateful that you all have taken an interest in trying to solve the plight of these poor women. It has been my privilege to work with different colleagues at different grades – nurses, cleaners, everybody. They are all vital members of the team and they are all trying to do something about it against tremendous odds. It is not one person; it is teamwork.

CHAIRMAN: Thank you very much. Now the RoyalCollege of Obstetricians and Gynaecologists’ International Office.

DR FALCONER: Baroness Tonge, thank you very much for inviting us to submit evidence. I am Tony Falconer and I am the International Officer of the RoyalCollege of Obstetricians and Gynaecologists. Dr Nynke van den Broek is a clinician with a huge experience in obstetrics in under-resourced countries and works at the LiverpoolSchool or Tropical Medicine. Our international office was launched in 2005 and we are working on many projects concerned with maternal health overseas.

Where we have an advantage is in our international membership. We are 11,000 members and fellows internationally and over half of those people work overseas, many in under-resources communities, so we have a huge network. We see ourselves as an international royal college and these networks are there to be used to the benefit of women. We are grateful for the support that you and other members of your panel have given to various initiatives to try and improve the plight of women overseas and we will do our best to address any questions you have.

CHAIRMAN: Thank you very much. And now Frances Day-Stirk is going to represent – I was going to say the oldest profession in the world but there is one that is recognised as older!

MS DAY-STIRK: Thank you very much for that, Baroness Tonge. I am Frances Day-Stirk from the Royal College of Midwives and I am Director of the department that, as well as being responsible for the professional activities of the college, also co-ordinates its international work. The RCM has a very long history of international work since it began in 1881 and we have a very clear position statement on supporting midwives and the development of midwives because we believe that good, well-educated professionals in-country impact favourably on the outcomes for women and their children. We believe that much of what you will hear today is well known but it is about getting it co-ordinated, getting the political will and dealing with the main issues that impact on both mortality and morbidity issues around the world.

CHAIRMAN: Thank you all very much and thank you for sticking to 100 words. My first question to all of you, and we are happy to hear from all of you or just one of you, is how on earth do we try to measure maternal morbidity? This is our problem. Unless we can give some really concrete figures people are not going to take us terribly seriously. How can we measure what we know to be this appalling problem worldwide?

DR KELLY: There have been many surveys done but some of them can be questioned because maybe you do not address the right people. Everyone who has been involved in fistula work in the developing world knows that once you provide an appropriate service, ideally free or at very low cost because they are poor women, patients come and they increase in number. They are the evaluators of how they are treated. Some of them give you a history of not being treated very kindly in hospitals when they were having their baby and various other things. In the 1970s consumer opinion and community health councils came in here. We have got to get that also from the women of Africa because they can guide us so much and work with us, and some of them, of course, have become brilliant surgeons themselves with no education and we have them now trained as village midwives.

CHAIRMAN: Thanks. Could I address that to the midwives next? You have a lot of international connections, as you all have. Figures?

MS DAY-STIRK: If you look at figures from the WHO, UNICEF and UNFPA, they do give a significant set of data about the morbidity issues, and if you look at the work done by the UK here in Beyond the Numbers, that also sets out a lot of the hidden disabilities that women suffer. It is very difficult to say how you measure it because each country will need to look at how it collects that data, but I am aware that work is being done along with the work that Gwyneth Lewis is doing.

CHAIRMAN: It is very difficult because women do not necessarily want to admit that they have got particular conditions.

MS DAY-STIRK: I think it is very difficult because even the numbers of deaths that we use are just an estimate because in many countries the data are not collected and there is a view that perhaps it is double the figure that we currently use.

CHAIRMAN: From the College point of view how far do your records go back? I always think if something is happening in developing countries now, we were once a developing country. At what stage did we tackle all these problems? We must have had loads of women in this country then with a history of prolapse and all the things we are going to be talking about. Do the Royal Colleges have statistics that go a long way back? Can we get any feel from what happened in our own country for what is happening in other countries?

DR FALCONER: I will talk a little bit and then Nynke, I think, will address your fundamental question about morbidity. The RCOG was started in 1929 and the reason it was started was because of maternal mortality in this country which in my lifetime it has shrunk hugely. The confidential inquiry goes back many years, over 50 years now, but we only have good data on mortality because the end point is so easily defined. Your question is incredibly penetrating because what is morbidity? To John it is a fistula. To Frances it may be psychological distress. Everyone will have their own spectrum of what is a morbid outcome, but I think Nynke has some contemporary information that may be helpful on this issue.

DR VAN DEN BROEK: I think your point is very pertinent, that a definition of morbidity is urgently needed. Clearly, there is a spectrum from not so severe morbidity to life-threatening morbidity, and if you do not survive that then mortality. There is an international working group at the moment hosted by WHO trying to compile all the different definitions that have been used in the research agenda. For example, South Africa has a very good definition of morbidity, severe acute morbidity, I think it is called. The London School of Tropical Medicine has done research on that. Our school has also done some research on that, so there is a variety of definitions and with the working group in WHO, which is called the Maternal Mortality and Morbidity Working Group, on which many of us sit, we are trying to come up with an internationally accepted definition that can be used to measure the problem, and once we have that it will be easier to provide some statistics that are comparable across countries.

CHAIRMAN: When will we be getting that? When is that work anticipated to be available?

DR VAN DEN BROEK: I think the first draft is being circulated at the moment.

CHAIRMAN: So this inquiry is quite timely then?

DR VAN DEN BROEK: It is very active. It is happening this year. It started earlier in the year. The definition has to be context-specific, so that whatever works in Latin America, for example, where they have fairly good health services and laboratory services and measures of morbidity can be generated, can be translated into conditions in north Nigeria or more rural African settings where you do not have laboratory tests to measure morbidity so they become more descriptive based on clinical signs. We do need a very good focused definition to start measuring this seriously and then I think it needs more attention and more research to document the problem.

CHAIRMAN: Do you think there are any archives in the Wellcome Institute or the College of Apothecaries or whatever that might help us?

DR VAN DEN BROEK: I think there are specific aspects of morbidity, so there is work done on anaemia, there is work done on fistulae, but there is not an all-encompassing definition.

CHAIRMAN: No, but on individual cases it might be helpful.

MS DAY-STIRK: Although there are no statistics, if you look at the Hansard reports going back to the turn of the century, certainly around the lobbying that the RCM, as it was then, did around maternal and newborn wellbeing, I think you will see much of what you are looking for in terms of the state of women and newborns in this country then.

LORD REA: Because the definitions are not clear it is extremely difficult to conduct surveys from existing data, so what would seem to be necessary would be to plan really careful sample studies in particular communities which might be expanded to represent the whole country if they are well-chosen samples. We then might have something to go on. I am not quite sure if such studies have been done or whether there are any such planned.

DR VAN DEN BROEK: A few research studies have been done and have come up with numbers of mortality versus morbidity. For example, the figures saying that for every mother that dies probably between 15 and 30 mothers have severe morbidity are from studies from all over the world but it is difficult to compare them. As soon as we have a good definition agreed at central level by the UN bodies and agencies it will be very timely to have immediate fact-finding with good samples that represent populations across the globe.

LORD REA: I am not sure if it was in your submission but it would be useful for us to have the references to those studies that have been going on.

DR FALCONER: Bob Pattinson in South Africa is doing work where he has been developing similar confidential inquiries into maternal death and along with that he is beginning to do near-miss work, but I do not know whether that is in public form or not yet.

DR VAN DEN BROEK: We can certainly provide evidence and I can ask WHO if they are happy to make preliminary reports available if that will help.

CHAIRMAN: Thanks very much indeed. It would be very helpful.

LORD REA: This is again a rather general question. I think all of you agree that the global community has so far failed to make maternal health a political priority. Can you give us some ideas about why this is so, considering that reproduction is so important in the future of the human race, and what is to be done to improve funding? What financial investments are needed and through what bodies to achieve proper access to reproductive health care and to reach the Millennium Development Goal number 5?

DR KELLY: I hate to keep emphasising it but the majority of those who suffer are poor women, and the families suffer too, of course; the children suffer if the mother dies. Mortality and morbidity are very closely related and we have examples of that. We have an example in Ethiopia in a rural area where Dr Catherine Hamlin said 20 years ago, “We do not see any fistulae from the area of that hospital”, and that is because that hospital has functioning, appropriate, emergency obstetric care, as would happen anywhere in the developed world 24 hours a day seven days a week. It is no use with one that stops at five o’clock and, perhaps more commonly, at five o’clock on a Friday. Also, there is the great problem of addressing transport at night. In most of the developing world that is a no-go area. You do not travel at night. Even ambulances can be hijacked. That is why, if you can detect some abnormality (you cannot detect all abnormalities that are going to happen in labour, you can detect some) then you have a set-up where that woman can wait in whatever you like to call it – a maternity waiting area. At this hospital in Attat we have information on 23,000 over 21 years. It is not easy to do but there are significant benefits for both perinatal mortality and maternal mortality.

LORD REA: That sounds like a shining example of how things should be done but my question is, how do we get something like that service elsewhere?

MS DAY-STIRK: I think there are many factors but the one that the RCM would like to highlight is that of gender. It is very much a gender issue. The status of women is not always recognised. I hate to say this, but in many countries women are dispensable. If you lose one wife you can find another one easily. Your cow or your goat might be more valuable than a woman, so there is a lot of work to be done around that. In terms of what could be done to improve the situation, it would be good to see some incentives linked to donor funds to look at improvement of women’s education and nutrition and legislation to support their reproductive rights. That is one way forward. I will just give you an example of the ICM (International Confederation of Midwives) programme that is running with UNFPA in 60 countries with poor maternal morbidity and mortality rates. In order for countries to become part of the programme there has to be commitment in-country from the government. That would do a number of things in order to get the funding support to develop their mechanisms of regulation, education and so on. Some sort of incentive like that might be a way forward.

LORD REA: I think you have hit the nail on the head with commitment in-country.

DR FALCONER: Not a lot keeps me awake at night but this question often does keep me awake, wondering why maternal mortality is not appreciated from the western world, particularly if you look at HIV/AIDS and the amount of time that is spent on that. We sometimes wonder if it is a conceptual difficulty because we are so privileged now in the West with our maternity services that we have no concept of what it is like for a mother to die or get a fistula. You do not see obstetric fistulae in the United Kingdom; they just do not occur. That is one thing. The second thing, I suppose, if you are very cynical, is that there is no money attached to maternal mortality like there is to HIV/AIDS. There are big drug budgets involved in that, so if you were very cynical you could say that other things are motivating people.

CHAIRMAN: And if you are even more cynical you would say because those conditions do not affect men.