Mothers betrayed

Every year half a million women die in childbirth, deaths easily prevented. Here Sarah Brown, wife o

Two weeks ago, at Mulago Hospital in Kampala, I sat down next to a mother called Sylvia, resting in bed with her newborn baby after a successful delivery, nearly ready to return to her husband and five older children.

But I also looked through a window into a room containing eight babies, none more than two days old, their little cots covered in malaria nets. The doctors explained to me that in each of these cases, and hundreds more like them in the same hospital each year, the mother had died in childbirth.

The causes of death varied from bleeding and infection to high blood pressure and failure to survive a Caesarean section - all so easily preventable by modern western standards. In Britain, for the same reasons, the death of a mother in childbirth was once a common hazard, a fixture of Victorian life.

Improvements over the past century in antenatal care, health education, and obstetric and gynaecological care have lowered the risks of childbirth. There may be more to do at home, particularly on the health risks to newborn babies. But nowadays, only seven in 100,000 women die when giving birth in Britain.

In sub-Saharan Africa, the conditions and health care for mothers in childbirth are often no better, and sometimes far worse, than we had in Victorian times. In 1987, more than 500,000 women were dying in pregnancy or childbirth every year across the world, 99 per cent of them in developing countries. More than half of all women were delivering their babies with no skilled birth attendant present.

It was because of this terrible toll that 20 years ago, the Global Safe Motherhood Initiative was launched by the World Health Organisation to try to reduce the rates of maternal death. In 2000, the United Nations recognised the shocking rates of maternal death and made their reduction one of the Millennium Development Goals. The fifth MDG committed the wealthiest nations to cut maternal mortality by three-quarters between 1990 and 2015.

Tragically, 20 years after the Global Safe Motherhood Initiative, seven years after the UN Millennium Summit, no progress has been made. If anything, the figures are worse. Of 211 million pregnancies worldwide in 2005, eight million women experienced life-threatening complications during pregnancy or childbirth.

Those with access to skilled care and services tended to survive. But 536,000 died, the vast majority in developing countries, 80 per cent of them totally avoidable. Millions more have continuing health difficulties following obstetric complications, making life after childbirth difficult and painful.

In sub-Saharan Africa, the number of mothers dying in childbirth is around one in 50: up to 100,000 women die each year, and hundreds of thousands of babies and older children are left without a mother.

Visit hospitals in Africa and it is easy to see why. While the Commonwealth Heads of Government Meeting was going on in Uganda, I visited labour wards and delivery rooms at Muhimbili Hospital in Dar es Salaam and Mulago Hospital in Kampala. They are both huge referral hospitals attracting many women from across each city, and they offer the only real emergency obstetric care in their areas.

Mulago alone sees the delivery of 33,000 babies a year, almost one hundred a day. Compare that to the Edinburgh Royal Infirmary where my children were born, which is considered a big UK facility and where just 6,000 babies are delivered each year.

In all my visits, I saw overstretched services at work, committed teams with too few con sultants, nurses and midwives, and insufficient equipment and technical provision. Shortages included basic supplies such as sutures and painkillers, which run out whenever there is an extra-busy day for Caesarean sections or other emergency procedures.

The governments in Tanzania and Uganda are doing their best to make progress.

The Tanzanian president, Jakaya Kikwete, told me this was a personal passion for him, and that his government had pledged to put dispensaries around the country that could also offer antenatal care. In Uganda, I saw the nearly completed refurbishment of a maternity block in the Mulago Hospital grounds. But still the death toll remains stubbornly high.

And what makes the lack of any progress on maternal mortality so depressing and frustrating is that, on other Millennium Development Goals, some progress - albeit slowly - is being made and things are beginning to improve. Millions more children are surviving infancy, receiving vaccinations and going to primary school than were in 2000, their life chances transformed by better health care and education. Even in the uphill struggle against Aids, great progress is being made. In Uganda, HIV infection has fallen from 16 per cent to 5 per cent in the past decade.

Yet we know that for hundreds of thousands of children each year, the improvements we make to their life chances through better edu cation and health care are cancelled out by the loss of their mother. For every mother who dies in childbirth, the life chances of a new baby - as well as its brothers and sisters - can be damaged beyond repair.

Avoidable deaths

It is obviously harder for a child to survive, grow and have a life with choices if there is no mother to provide care, food, protection and education. The statistics bear this out. A study in Indonesia showed that 14 per cent of children aged six to ten who had lost mothers dropped out of school, compared to only 7 per cent of those who had not. Poverty as an adult was far more likely for the former group.

The same study showed that children without mothers were four times more likely to die in their early years - usually of malnutrition or disease - compared to other children.

Internationally, pressure is growing, through the White Ribbon Alliance, a global campaign group dedicated to highlighting the avoidable tragedy of maternal death, supported by the WHO's Making Pregnancy Safer campaign and the Partnership for Maternal, Newborn and Child Health. In the UK, the White Ribbon Alliance is led by the Royal College of Obstetricians and Gynaecologists (RCOG) and I sit on its international advisory group. This has given me the opportunity to meet some of the world's leading experts in this field. It has opened my eyes to the impact of maternal death on the life chances of infants.

The general causes are well understood: high fertility rates lead to greater pressure on resources, inadequate and inaccessible health care makes childbirth inherently risky, and women's low status economically and culturally affects their access to health services and the priority they are given.

There is also broad agreement on the solutions required: greater resources, better education, better access to emergency care, availability of antenatal care to spot problems in advance and quick referrals for mothers with complications.

The RCOG International Office has designed a course teaching young consultants essential obstetric and newborn care. The course is available in Tanzania and Kenya, and I hope it will soon be extended to Uganda. Accompanied by Tony Falconer, RCOG senior vice-president, I met a young doctor in the antenatal clinic at Muhimbili Hospital who had completed the course two months before, and thought his training had already helped him save lives.

The RCOG is taking this work further. In South Africa, it is working to help obstetric experts develop a training package for all local doctors in their third postgraduate year, generally spent in more remote conditions. Momentum is building. I am hopeful that a special session will be devoted to maternal death at next year's international summit in Davos and the Bill and Melinda Gates Foundation is funding projects around the world to raise awareness.

At home, just over a month ago, the International Development Secretary, Douglas Alexander, announced at a conference in London that the UK would commit an extra £100m towards improvements in reproductive health. To meet any of the Millennium Development Goals, we need the will, the means and the momentum. We have seen this in relation to vaccinations, free education and the fight against Aids. Now we must see it on the issue of maternal death, where no significant progress has been made, not just in the past seven years, but in the past two decades.

Each developing country needs a strategic health plan that takes account of local situations, expanding services so that populated central and remote areas alike acquire trained people and resources. The investment needed to improve maternal health is small, but the gains for the poorest children in the world will be huge. We must make 2008 the first year of progress on this neglected Millennium Development Goal.

Sarah Brown sits on the international advisory board of the Royal College of Obstetricians. As founder of the Jennifer Brown Fund, she has been closely involved for the past six years in the area of infant and maternal health

This article first appeared in the 10 December 2007 issue of the New Statesman, How New Labour turned toxic

Edel Rodriguez for New Statesman
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Rehearsing for war

From the Middle East to North Korea, Donald Trump is reasserting US military strength and intensifying the rivalry among the great powers.

As Vice-President Mike Pence arrived in South Korea from Washington on Sunday, he announced that the “era of strategic patience”, in which the US sought to monitor and manage the nuclear threat from North Korea without pushing the matter for fear of escalation, was over. “President Trump has made it clear that the patience of the United States and our allies in this region has run out and we want to see change,” Pence declared. The heat under a crisis that had already been bubbling ominously was turned up another notch.

Much has been written in recent years about the stability provided by the post-1945 world order and the dangers of letting it crumble. The conflict in Korea provided the first big test of that order almost 70 years ago, but the difficulty was never really resolved. It remains the proverbial “wicked problem” in international affairs, “frozen” in an obsessively monitored and deeply uneasy stalemate, demarcated by the Demilitarised Zone: a line 160 miles long and roughly two and a half miles wide scored across the middle of the Korean Peninsula, drawn with superpower supervision in 1953. Partition has allowed a strong and ­successful state to flourish in the South while the North has survived in a state of ­arrested development.

The problem has been passed down from generation to generation because attempting to solve the issue risked opening a Pandora’s box. The risks included the unleashing of huge military force, potential world war and a refugee crisis on a scale that could severely destabilise even China. By the 1990s, it was clear that the North Korean regime had fastened upon another strategy for survival as the Cold War passed into history and its sponsors in Beijing and Moscow began to question the value of such an ally: the acquisition of nuclear warheads. Pyongyang has long had the firepower to flatten Seoul in a matter of hours. The mission since has been to develop its missile technology to carry that material as far as possible – certainly to Japan, but ideally also to the west coast of the United States.

The day after Pence’s announcement, the US and South Korea undertook a joint air and army exercise to ensure readiness in the event of an attack from the North. This followed a joint naval war game earlier in the week and the US decision to send a navy group led by the nuclear-powered aircraft carrier USS Carl Vinson, which Donald Trump described as an “armada”, to the region. No sooner had the fleet appeared than Japanese sources reported that it had been followed by Chinese and Russian submarines as it entered North Korean waters. Such are the great-power manoeuvres of the 21st century – whether on air, sea or land – in which the world’s most potent military machines shadow the moves of their competitors, and openly rehearse for war.

***

Asia has not had a major inter-state war since the 1970s but it is not immune from the tragedies of power politics that have beset other rapidly developing parts of the world. Across the region, military spending is rising fast as states jostle in anticipation of a changing balance of power.

The purpose of Pence’s Asia-Pacific tour is to offer reassurance to America’s allies in the region, which have been watching the rise of China, in particular, with trepidation. The stark change of tone emanating from the White House – and change of gear – has been noted. After years of steady consistency in US grand strategy, there is a sense of a building crisis and the Americans are being watched in anticipation of their next move more closely than they have been scrutinised in many years.

Before he left South Korea, Pence also visited Panmunjom, where the 1953 armistice was signed at the end of the Korean War, as well as Camp Bonifas, a UN military compound near the Demilitarised Zone, set up to monitor the ceasefire that followed. It is an eerie echo from the past that Pence’s own father served in the war that divided the country. Edward Pence was awarded the Bronze Star on 15 April 1953 for heroic service. The vice-president proudly displays the medal, and a photo of his father receiving it, in his office. He is no doubt aware of the costs of a conflict in which an estimated 36,000 of his countrymen were killed.

Just over a thousand British soldiers also lost their lives in the Korean War after being sent to fight in a joint UN force. But it was far more deadly still for the peoples of the Korean Peninsula, killing more than a million people, including 400,000 troops for the People’s Volunteer Army, among whom was Mao Anying, the eldest son of Chairman Mao, the leader of the Communist Party of China and protector of the North.

History throws up strange parallels. When the Korean War began in 1950 it was understood to be the first serious test of the international system established after the Second World War. It is striking just how many of the same ingredients remain, including the identity of some of the main protagonists. On 25 June 1950, a border conflict between North and South Korea escalated into full-scale war when Kim Il-sung’s Korean People’s Army – backed by China, and with the tacit support of the Soviet Union – invaded the Republic of Korea in the south, claiming that it represented the legitimate government of all Korea. This is a claim that the regime of his grandson Kim Jong-un has not abandoned to this day.

Two days after the invasion, on 27 June, the UN Security Council voted to send a joint force, under General Douglas MacArthur of the US, the former supreme commander of Allied forces in the south-west Pacific area, to protect the sovereignty of the South and repel the invaders. Much more was at stake than the question of territorial integrity or preserving international law. By bringing the Americans into confrontation with the Chinese – and with the Russians seen to be the steering hand in the background – the conflict had all the ingredients for rapid escalation.

From the start, there were concerns that the Americans might overdo the brinkmanship, even under the cautious leadership of Harry Truman. Fears that the self-confident MacArthur would exceed his brief were confirmed when the UN forces pushed back into North Korea in October. In response, the Chinese Communists, who believed that MacArthur had designs on China itself, flooded across the Yalu River in their tens of thousands.

It was in the autumn of 1950 that the danger of another world war, this one involving nuclear weapons, reached its peak. On 28 November, after a grave reverse for the UN forces, MacArthur stated that the advent of 200,000 Chinese had created “an entirely new war”, with much higher stakes than before. Suddenly, the prospect that the US might resort to using an atomic bomb against the North Koreans, or even the Chinese forces, seemed plausible.

While the nuclear scare passed, the war rumbled on towards an ugly stalemate over the next three years. A temporary solution of sorts was found with the 1953 armistice. But there was no resolution to Korea’s frozen war. In a way that no other totalitarian state has managed, the North zipped itself into a hermetically sealed chamber, preserving a three-generation dictatorship that is both comically anachronistic and frighteningly modern in its missile technology.

***

Some of this complicated backstory was explained to Donald Trump by China’s president, Xi Jinping, during his recent visit to the United States. Trump – who had been pressuring China to do more to deal with the North Korean regime – appears to have been receptive to what he heard.

“After listening for ten minutes,” he said, “I realised it’s not so easy.”

This is the first critical test of the “new era in great-power relations” which Xi has been floating for a number of years, but Trump has now decided to put to the test. According to Trump’s most recent tweets, Beijing has continued to work with the US on the North Korea problem. He has welcomed its contribution but insisted that America’s own willingness to deal with the problem does not depend on China. In other words, there is no master plan being played out here, even if – as seems credible – America did hack North Korea’s latest missile launch to make it a damp squib.

The Trump administration is not creating the conditions for a new long game, building a fresh multilateral consensus to contain the North Korean threat. Instead, with a newfound sense of momentum serving as a tail wind, it senses a moment to “solve” one of the longest-running and most treacherous problems in international affairs. It has decided, at the very least, to severely clip the wings of Kim Jong-un’s regime. And in doing so, it has set out to demonstrate that when America speaks, it speaks with effect.

Like much current presidential policy, “the Trump doctrine” is being made on the hoof. Much of the hyperactivity of the past month or so was not scripted but emerged in response to overt challenges – beginning in Damascus and panning to Pyongyang – to the United States and the “red lines” it has laid down in the past. One foundation stone of Trump’s approach to the world is firmly in place, however: the willingness to reassert US military power with swift and decisive effect. The idea that the “America First” slogan implied anything resembling isolationism is crumbling. The growing sense that it does imply unsentimental and unvarnished power politics in the name of the US interest rather than multilateral niceties is closer to the truth.

Under Barack Obama, the US sought to withdraw from those areas in which he felt that the US had overstretched itself under his predecessor. Obama opted for a more rapier-like and cost-effective form of power projection. He drew down from formal military operations in Iraq and Afghanistan, while presiding over a huge uptick in drone warfare, cyber capabilities and selective but deadly use of special operations. Much of the full range of US power was submerged in various “secret wars”, and the diplomatic compass was reset to pivot east. This was because, as a legacy of the 9/11 attacks, national security was geared towards the containment of an elusive and amorphous enemy – various offshoots of the global jihad movement – that operated on the periphery of America’s radar.

But the real metrics of great power are those now on display off the coast of North Korea. For all the advances in drone technology, the missiles that cause the gravest threats to humanity are those on the scale that the North Korean regime is attempting to build. Trump’s test was one that a president of the United States would have to face sooner rather than later.

Not since Ronald Reagan has the US been so willing to engage in naked displays of its own military potency in quick succession – and seek to gather diplomatic yields from them as swiftly as possible. The past fortnight brought a missile attack on an airbase manned by the Assad regime – changing the tenor of US-Russian relations overnight – and the dropping of the so-called Moab (“mother of all bombs”) on an Isis affiliate in Afghanistan. The latter was a far cry from the “clear, hold, build” counterinsurgency operations in vogue half a decade ago. But it did fit with a campaign promise by the new president that he would “bomb the shit out of Isis” should the opportunity arise.

Does this fit into a wider pattern or constitute a new approach? The Trump administration is eager to leverage any opening that might have been created. In Seoul, Pence wasted no time in joining the dots: “the world witnessed the strength and resolve of our new president in actions taken in Syria and Afghanistan”. North Korea, he continued, “would do well not to test his resolve, or the strength of the armed forces of the United States in this region”.

It is the generals who have increasingly set the tone for Trump’s foreign policy. During the 2016 election campaign, he promised to give the Pentagon more leeway than it had under Obama to focus on “winning”. The new national security adviser, H R McMaster, and the defence secretary, General James Mattis, are now the steering hands.

Neither man has followed the rather crass and short-sighted fashion for running down diplomacy. Mattis once said that if the state department budget was cut, he would need more ammunition. McMaster is an urbane thinker who knows that the use of force must always be carefully calibrated and is just one tool in a continuum of factors. In this respect, it is a problem that so many jobs in the state department remain unfilled. Now that muscle has been flexed, the experienced negotiators and diplomats should be flooding through the door.

***

The policy of “strategic patience” was based on an understandable calculation. But, in hindsight, it does appear that North Korea has suffered from neglect. Mitchell B Reiss, one of the most experienced diplomats who led efforts on North Korea in the 1990s, notes that, despite unprecedented co-operation between the US and China in recent weeks, including open threats of economic pressure and military action, they were still unable to prevent North Korea from testing ballistic missiles on 16 April. Even though the missiles exploded immediately after lift off, “The failure of Washington and Beijing to stop the test in the first place has important implications for the Trump administration’s future policy options and for stability in north-east Asia.”

In Reiss’s view, it is “highly unlikely that the North can be cajoled, threatened or given incentives to surrender its nuclear weapons”. The uncomfortable truth is that “short of regime change, which could inflame the entire Korean Peninsula in war”, the US cannot halt the North’s nuclear weapons programme. But that does not mean there are no options. Slowing the pace and raising the costs would be “prudent steps”. More, too, could be done, Reiss says, to “interdict imports of sensitive technologies, to sanction Chinese and other nationals who act as purchasing agents for the nuclear and missile programmes, and to punish Chinese banks that help finance these programmes through so-called secondary sanctions”.

In the end, so much comes down to US-China relations. Could this be the basis for a reset and a new accommodation between Beijing and Washington? How much further is China willing to go to use its leverage on the North, which depends on it for energy and food? And how patient will the Trump administration be if its new strategy does not yield tangible results of the sort that are sometimes elusive in the long and often open-ended game of deterrence? 

John Bew is a New Statesman contributing writer and the author of “Realpolitik: a History” (Oxford University Press)

John Bew is a New Statesman contributing writer. His most recent book, Realpolitik: A History, is published by Oxford University Press.

This article first appeared in the 20 April 2017 issue of the New Statesman, May's gamble

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