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Making Motherhood Safe in Developing Countries: Perspective
Making Motherhood Safe in Developing Countries: Perspective
be substantially higher than the medical inflation and health in- osity of ones insurance policy.
cost of a deduction. surance premiums, is a third di- Regional differences in health care
To address the lack of incen- mension that has troubled critics. prices, practice patterns, and pa-
tives for low-income families, the The deduction could be indexed to tient preferences all affect the cost
President has proposed the Af- the medical care component of the of insurance, as do the size, aver-
fordable Choices Initiative, under CPI, although such an adjustment age age, and health risks of the
which states could use their Med- would still fail to accommodate group with which one is pooled.
icaid disproportionate-share mon- real increases in health care spend- These complexities will make it
ey and certain federal grants to ing. However, indexing the stan- difficult to move down the path
give low-income and vulnerable dard deduction at a higher rate prescribed by the President absent
populations access to basic pri- would increase the proposals cost universal access to national plans
vate insurance. This initiative rep- substantially. such as the Federal Employees
resents a weak and uncertain re- Although the Presidents pro- Health Benefits Program.
sponse to a serious challenge. posals are unlikely to gain much Dr. Reischauer reports serving on the
advisory board of the National Institute of
A second concern is the inad- traction in Congress, they could Health Care Management.
equacy of the state-regulated indi- start a long-overdue discussion of
vidual insurance market, to which the extent to which tax preferenc- An interview with Congressman Pete
many more would turn if the new es should be used to encourage Stark (D-CA) and Senator Chuck
deduction accelerated the erosion the purchase of health insurance Grassley (R-IA) can be heard at www.
of employer-sponsored insurance. and the forms that such encour- nejm.org.
To address this concern, states agement should take. Any effort Dr. Reischauer is the president of the Urban
could be required to revise their to make the tax treatment more Institute, Washington, DC.
individual insurance-market reg- rational, however, will come up 1. Burman LE, Furman J, Leiserson G, Wil-
ulations to meet some minimum against the entrenched interests of liams R. The presidents proposed standard
federal standards. Alternatively, those who stand to lose. It would deduction. Washington, DC: Tax Policy Cen-
ter, February 9, 2007. (Accessed March 15,
those without employer-sponsored not, for instance, prove broadly ac- 2007, at http://www.taxpolicycenter.org/
coverage could be permitted to buy ceptable to limit the tax subsidies publications/template.cfm?PubID=10028.)
either Medicare coverage or a plan granted for very expensive health 2. Proposed standard deduction for health
insurance, distribution of federal tax change
offered through the Federal Em- insurance policies, because not all by cash income class, 2009. Washington, DC:
ployees Health Benefits Program. such policies provide gold-plated Tax Policy Center, February 6, 2007. (Accessed
The decision to index the pro- coverage: insurance premiums and March 15, 2007, at http://www.taxpolicycenter.
org/TaxModel/tmdb/TMTemplate.cfm?
posed deduction to the CPI, which health care spending in general Docid=1445&DocTypeID=1.)
increases much more slowly than depend on more than the gener- Copyright 2007 Massachusetts Medical Society.
contribute to significant reduc- thesia, with the support of the Unlike the situation 20 years
tions in maternal mortality. Federation of Obstetrics and Gyn- ago, improving maternal health is
An effort is also under way to aecological Societies of India. now high on the global develop-
ensure that all pregnant women Maximizing the potential of alter- ment agenda. One of the eight
have a skilled attendant at deliv- native types of health care work- United Nations Millennium Devel-
ery an accredited health care ers will require this kind of lead- opment Goals embraced by 189
professional (e.g., a doctor, mid- ership and cooperation on the part countries in 2000 is to reduce the
wife, or nurse) who can conduct of professional societies. maternal mortality ratio by 75%
normal deliveries, identify and Another major constraint is the by 2015. Most African and some
manage complications, and refer cost of obtaining care. Even where Asian countries are not on track to
women to the next level of care. services are officially free, patients meet this target, but efforts should
To be effective, skilled attendants in low-resource countries often in- continue unabated. Policymakers
must have access to drugs and cur catastrophic costs to obtain and health care professionals must
equipment and must be backed by the care they need in order to sur- continue learning from successful,
an infrastructure that includes re- vive. These costs include those of and unsuccessful, program mod-
ferral systems and good-quality purchasing supplies and drugs in els and work to scale up effective
health facilities. the market because they are un- approaches. To make such expan-
Innovative projects are in prog- available in the facility, securing sion possible, donors must sub-
ress in a number of countries, in- transport to the facility, and mak- stantially increase funding for
volving United Nations agencies, ing informal payments often re- maternal health programs and re-
nonprofit organizations, academ- quired to actually receive care once search, and the governments of
ic institutions, nongovernmental the patient, supplies, and provid- developing countries must estab-
organizations, professional soci- ers are in place. For ministries of lish supportive policies. Although
eties, and governments. A major health struggling to strengthen every country has its own history
constraint on increasing access to their health care systems and ad- and challenges, accelerating prog-
lifesaving services is the severe dress inequity, resources often fall ress is not impossible if political
shortage of skilled health care well short of the minimum levels will can be translated into action.
workers in developing countries, needed.
especially in rural areas. However, Access to emergency obstetrical Dr. Rosenfield is the dean and a professor
of public health and obstetrics and gynecol-
highly trained specialists are not care is essential to efforts to re- ogy, Ms. Min a research associate, and Ms.
necessary. Well-trained nurses and duce maternal mortality. Several Freedman director of the Averting Maternal
midwives can provide basic emer- countries have demonstrated that Death and Disability Program and a profes-
sor of clinical public health at the Mailman
gency obstetrical services, such as great strides can be made when School of Public Health, Columbia Univer-
assisted vaginal delivery and the maternal health is a political pri- sity, New York.
administration of antibiotics and ority. In Sri Lanka and Malaysia,
1. Rosenfield A, Maine D. Maternal mortali-
other drugs. In Mozambique, the maternal mortality ratios in the ty a neglected tragedy: where is the M in
Ministry of Health has trained early 1950s were more than 500 MCH? Lancet 1985;2:83-5.
assistant medical officers (nonphy- deaths per 100,000 live births. In 2. Abou Zahr C. Maternal morality in 2000:
estimates developed by WHO, UNICEF and
sicians) to become surgical techni- subsequent decades, both coun- UNFPA. Geneva: World Health Organization,
cians and safely perform emergen- tries were able to halve these ra- 2004.
cy obstetrical surgery, including tios every 6 to 12 years.4 Strategies 3. United Nations Population Fund. Cam-
paign to End Fistula: frequently asked ques-
cesarean deliveries. These tc- evolved over time and included tions. (Accessed March 15, 2007, at http://
nicos de cirurgia now perform professionalizing midwifery, en- www.endfistula.org/q_a.htm.)
most emergency obstetrical sur- suring skilled attendance at child- 4. Pathmanathan I, Liljestrand J, Martins
JM. A et al. Investing in maternal health:
gery in rural hospitals. A similar birth, and developing a system of learning from Malaysia and Sri Lanka. Wash-
approach is being implemented in health care facilities accessible to ington, DC: World Bank, 2003.
Tanzania and Malawi. In India, all women. Thailand, Egypt, and 5. Koblinsky MA, ed. Reducing maternal
mortality: learning from Bolivia, China, Egypt,
general practice physicians are be- Honduras have also achieved sub- Honduras, Indonesia, Jamaica, and Zimba-
ing trained to perform cesarean stantial reductions in maternal bwe. Washington, DC: World Bank, 2003.
deliveries and administer anes- mortality.5 Copyright 2007 Massachusetts Medical Society.