Reaching the marginalized: EFA global monitoring report, 2010; 2010

010CHAPTER 22Education for All Global Monitoring ReportMore than onein three birthsin developingcountries takeplace withouta skilled birthattendantUnsafe pregnancy and childbirth exact an immensehuman toll. An estimated half a million women losetheir lives each year from pregnancy and birthrelatedcauses – and for every death another thirtywomen suffer severe long-term injuries. Almost allthese deaths and injuries could be averted throughaccess to antenatal care, skilled attendance duringpregnancy and emergency obstetric care. Poormaternal health, inadequate nutrition and limitedaccess to care are also implicated in the deaths ofthe 4 million newborns who do not survive their firstmonth (Lawn et al., 2006). Two conditions – birthasphyxia and sepsis with pneumonia – cause nearly60% of these deaths. The real cause, however, islimited access to skilled health professionals at birthand a failure to prioritize maternal and child healthin national policy (Thea and Qazi, 2008).This ‘needless human tragedy’ (UNICEF, 2008b)goes beyond maternal and child mortality andimmediate health risks. Undernutrition in utero, lowbirth weight and heightened vulnerability to sicknessafter birth can cause direct structural damage to thebrain that impairs cognitive development and lockschildren into a future of underachievement. Widerhealth risks during pregnancy and childbirth alsohave consequences for education:Maternal iodine deficiency in pregnancy causesan estimated 38 million children to be borneach year facing risks of mental impairmentand congenital abnormalities (UNICEF, 2007b).Anaemia, which affects around half of allpregnant women, heightens the risks associatedwith pregnancy and reduces prospects for childsurvival (UNICEF, 2008b).Around half of the stunting observed in infantsoccurs in the uterus and the remainder duringthe first two years of life (Victoria et al., 2008).of sexual and reproductive health, early marriageand poor access to information all contribute.Providing quality health careInadequate maternal and child health care isholding back advances in education. Progresstowards the Millennium Development Goal targetof a three-quarters reduction in maternal deathsby 2015 has been close to zero. Meanwhile, limitedimprovements in survival in the first month of lifeare preventing progress towards the target onchild mortality.One of the most urgent priorities is providingquality health services. Intrauterine growthrestrictions and maternal micronutrient deficienciescan be readily detected through antenatal care andtreated at little cost. Access to facilities providingskilled attendance at birth, emergency obstetriccare and post-natal care could prevent over 80%of maternal and neonatal deaths, and set childrenon course for a healthy future (UNICEF, 2008b).Yet more than one in three births in developingcountries take place without a skilled birthattendant. Skilled attendance rates are lowestin South Asia (41%) and sub-Saharan Africa (45%)(UNICEF, 2008b). Not coincidentally, these are theregions with the highest maternal mortality rates.Poverty undermines maternal health in severalways. It heightens exposure to threats such asmalnutrition and infectious disease. It can alsoreduce access to vital health care, either becausecare is lacking or because it is unaffordable tothe very poor. The poverty risk factor is graphicallycaptured in a UNICEF review of evidence fromfifty household surveys that found that neonatalmortality rates among the poorest 20% weretypically 20% to 50% higher than for the wealthiestquintile (UNICEF, 2008b). These health inequalitiesfuel education disparities later in life.The absence of skilled health personnel duringdelivery costs lives and leaves children facinglifetime disadvantages. Asphyxia contributesto around one-quarter of newborn deathsand results in about 1 million children sufferinglearning difficulties and disabilities such ascerebral palsy (WHO, 2005).Access to health provision is not the only barrier toimproved child and maternal care. Many underlyingproblems associated with pregnancy and childbirthreflect a failure to protect women’s rights. Lowstatus, heavy workloads, a lack of voice in mattersThe poorest mothers and children are oftenunderserved along the whole continuum of care.In South Asia, being poor reduces by a factor offive the probability of having a skilled health personin attendance during delivery. Even controlling forpoverty, indigenous people and ethnic minorities areoften severely disadvantaged. In Guatemala, nonindigenouswomen are more than twice as likely astheir indigenous counterparts to give birth in apublic health facility with trained personnel. Thefactors excluding poor and vulnerable householdsfrom basic maternal and child health services varyby country but include cost, distance and the poor46