22 The World Health Report 2005 Table 2.1 Factors hindering progress than with the failure of the strategy itself a new commitment is needed to create Decline of More than two years Adult HIV the conditions for moving towards effec- child mortality of humanitarian crisis since 1992 (weighted average) 1990-2002 in 1995 verage tive implementation international dollars CONTEXT MATTERS 93 countries are 3/93 countries 20049(0ECD) on track 4179(non-0ECD) Poverty undermines progress 51 countries are making 10/51 countries 07 Many of the countries whose child mor- slower progress tality rates are stagnating or reversing are oor in terms of gross domestic product 14 countries are 8/14 countries 10.2 others are facing economic downturn. (excluding South Africa) Conventional wisdom has it that income 29 countries have 11/29 countries poverty is on its way out because the stagnating mortality proportion and the total number of peo Towards Millennium Development Goal 4 ple around the world living on less than S1 per day is decreasing (1). However almost all of this progress has been made in Asia. Sub-Saharan Africa, where most of the countries whose child mortality rates have stagnated or reversed are to be found, has emerged as the region with the highest incidence of extreme poverty, and the greatest depth of poverty(2). Furthermore, the average income of poor people in Africa has been falling over time, in contrast with that of poor people in the rest of the developing world ( 3) But poverty also influences maternal health. When women die in childbirth it is usu- ally the result of a cascade of breakdowns in their interactions with the health system delays in seeking care, inability to act on medical advice, and failure of the health system to provide adequate or timely care. These breakdowns are more likely to occur and to come together into a fateful combination when the macroeconomic and social contexts deteriorate In Mongolia, for example, widespread social chaos and economic collapse followed the introduction of economic"shock therapy"in the early 1990s(4, 5), with a rapid increase in unemployment and widespread poverty. Government ex- Box 2.1 Economic crisis and health system meltdown: a fatal cascade of events shnyam, a 41-year-old housewife, was a very she did not follow their advice and of these serious symptoms, the doctor urged or migrant from the countryside to a provin- pregnant again. She did not seek prenatal care, her to go to the provincial hospital's maternity cial capital of Mongolia. She and her husband but the family doctor discovered her pregnancy waiting home. However, her admission was were unemployed and often homeless, with six during an antenatal examination of her 18- delayed for over a week to solve bureaucratic children. During her last pregnancy Dashnyam old daughter. Because of Dashnyam's history issues, initially because she had no proof of had oedema and pre-eclampsia and required and age, and because she said that she did not having health insurance, and then because manual extraction of the placenta. Afterwards, want the child, the family doctor urged her to go there were no beds available. Eventuall she said she wanted no more children and was to the provincial hospital for an abortion. How- Dashnyam delivered via caesarean section given an intrauterine device(IUD). She had ever, by the time she had collected sufficient but suffered severe haemorrhage. After delay problems with the IUD and finally, in 2002 after funds, her pregnancy was too far advanced and in finding the anaesthetist, the bleeding years of use, she asked to have it removed abortion was no longer an option. She returned eventually stopped by emergency surgery, but ecause of pelvic inflammatory disease and home and received antenatal care from the the hospital had no blood for transfusion. She associated pain. The obstetrician who removed family doctor. As she came closer to term, she died from haemorrhagic shock. Names and the IUd urged her to use another form of birth manifested symptoms of pre-eclampsia -high places have been changed control, and her primary care physician gave her blood pressure and oedema. Because of her the same advice. For reasons that are unclear, age, history of complications, and the presence Source: (7).22 The World Health Report 2005 than with the failure of the strategy itself. A new commitment is needed to create the conditions for moving towards effec￾tive implementation. CONTEXT MATTERS Poverty undermines progress Many of the countries whose child mor￾tality rates are stagnating or reversing are poor in terms of gross domestic product; others are facing economic downturn. Conventional wisdom has it that income poverty is on its way out because the proportion and the total number of peo￾ple around the world living on less than US$ 1 per day is decreasing (1). However, almost all of this progress has been made in Asia. Sub-Saharan Africa, where most of the countries whose child mortality rates have stagnated or reversed are to be found, has emerged as the region with the highest incidence of extreme poverty, and the greatest depth of poverty (2). Furthermore, the average income of poor people in Africa has been falling over time, in contrast with that of poor people in the rest of the developing world (3). But poverty also influences maternal health. When women die in childbirth it is usu￾ally the result of a cascade of breakdowns in their interactions with the health system: delays in seeking care, inability to act on medical advice, and failure of the health system to provide adequate or timely care. These breakdowns are more likely to occur and to come together into a fateful combination when the macroeconomic and social contexts deteriorate. In Mongolia, for example, widespread social chaos and economic collapse followed the introduction of economic “shock therapy” in the early 1990s (4, 5), with a rapid increase in unemployment and widespread poverty. Government ex￾she did not follow their advice and was soon pregnant again. She did not seek prenatal care, but the family doctor discovered her pregnancy during an antenatal examination of her 18-year￾old daughter. Because of Dashnyam’s history and age, and because she said that she did not want the child, the family doctor urged her to go to the provincial hospital for an abortion. How￾ever, by the time she had collected sufficient funds, her pregnancy was too far advanced and abortion was no longer an option. She returned home and received antenatal care from the family doctor. As she came closer to term, she manifested symptoms of pre-eclampsia – high blood pressure and oedema. Because of her age, history of complications, and the presence Dashnyam, a 41-year-old housewife, was a very poor migrant from the countryside to a provin￾cial capital of Mongolia. She and her husband were unemployed and often homeless, with six children. During her last pregnancy Dashnyam had oedema and pre-eclampsia and required manual extraction of the placenta. Afterwards, she said she wanted no more children and was given an intrauterine device (IUD). She had problems with the IUD and finally, in 2002 after six years of use, she asked to have it removed because of pelvic inflammatory disease and associated pain. The obstetrician who removed the IUD urged her to use another form of birth control, and her primary care physician gave her the same advice. For reasons that are unclear, of these serious symptoms, the doctor urged her to go to the provincial hospital’s maternity waiting home. However, her admission was delayed for over a week to solve bureaucratic issues, initially because she had no proof of having health insurance, and then because there were no beds available. Eventually, Dashnyam delivered via caesarean section, but suffered severe haemorrhage. After delay in finding the anaesthetist, the bleeding was eventually stopped by emergency surgery, but the hospital had no blood for transfusion. She died from haemorrhagic shock. (Names and places have been changed.) Source: (7). Table 2.1 Factors hindering progress Decline of More than two years Adult HIV GDP per capita child mortality of humanitarian prevalence rate (weighted average crisis since 1992 (weighted average) 1990–2002 in 1995 international dollars) 93 countries are 3/93 countries 0.3 20 049 (OECD) on tracka 4179 (non-OECD) 51 countries are making 10/51 countries 0.7 2657 slower progressa 14 countries are 8/14 countries 10.2 1627 in reversal (excluding South Africa) 29 countries have 11/29 countries 4.1 896 stagnating mortality a Towards Millennium Development Goal 4. Box 2.1 Economic crisis and health system meltdown: a fatal cascade of events