Women Deliver Conference

June 7, 2010

Prepared remarks by Melinda French Gates, Co-chair and Trustee

Three months ago, I traveled to a village in the Indian state of Uttar Pradesh, where I met a young mother named Rukmini. Six days before, she’d given birth to a daughter she named Durga, after the goddess of power.

According to custom, Rukmini and Durga had remained in the same room since the birth. But on this day, the sixth day, Rukmini prepared for a ceremony that celebrated the special bond between mother and child. It is called Chhathi.

Rukmini bathed and dressed Durga in new clothes for the first time, and she put on a stunning, deep-crimson sari. In the courtyard, her neighbors were drumming and singing songs.

Finally, Rukmini emerged into the light of day, holding Durga in her arms. She took seven turns around the courtyard, threw colored grains of rice in the air, and accepted gifts of a few rupees from the women who had come to bless the baby.

Then Rukmini held Durga up to present her to the sun god. In the bright sunlight of late afternoon, she thanked him for a healthy birth and asked for his blessing.

While I was watching this, I kept thinking about the overwhelming joy and hope I felt when each one of my three children was born.

These are powerful feelings. No matter who you are, no matter where you live, it is incredibly moving to hold a healthy baby in your arms, to hold the future in your hands.

But tens of millions of women never get to experience that moment of beauty. For these women, childbirth is filled not with joy, but with dread, pain, and sorrow.

They know they might die during the delivery. If they survive the delivery, they are terrified their baby is going to die on the first day, or in the first week, of life.

It is not that the world doesn’t know how to save the 350,000 mothers and 3 million newborns who die every year. It is that we haven’t tried hard enough.

Policymakers in both rich and poor countries have treated women and children as if they matter less than men. They have squandered opportunities to improve their health.

The world hasn’t come together to do what’s necessary to save women’s and children’s lives.

Now, the world is changing. You are changing it.

In this room, there are health experts who worked tirelessly for women and children, even when it was lonely work.

There are advocates who kept up the drumbeat, even when others were silent.

There are government officials who listened, and acted, even when others were deaf and dormant.

Prime Minister Jens Stoltenberg of Norway set an example years ago when he insisted on funding women’s and children’s health generously, even though his political opponents used the issue against him.

Now, at least a dozen donor countries are following his lead, including the United States, which is making women and children a focus of its Global Health Initiative.

Secretary General Ban Ki-Moon is launching a detailed Joint Action Plan to help countries work together on maternal and child health – and to hold them accountable for progress toward the Millennium Development Goals.

Thanks to you – and to heroes like you – women and children are finally at the top of the global agenda – and that is where they are going to stay.

We have the momentum now.

We can make a new world for poor women and children: a world in which every birth is a promise – a promise for a better future.

Our work will not be easy. Women and children have been neglected for centuries. But their resilience – and our ambition – are greater than any obstacle we face.

One of these obstacles is more imposing than all the others. It is not a parasite or a virus. It is not a logistical challenge, like keeping vaccines cold. This obstacle is a belief – the belief that we just have to accept the fact that mothers and their babies die.

This belief has been with us for thousands of years. And that’s understandable, because for most of history, we were powerless to stop the deaths of mothers and babies. In the face of a relentless death toll, people around the world came to believe that these deaths were inevitable.

Now we do have the power to save women and children. Yet, in many countries, the belief that death is inevitable, and therefore acceptable, hasn’t changed.

We don’t have to tolerate fatalism.

Sri Lanka is a powerful example of what happens when we stop taking women’s and children’s deaths for granted. The Sri Lankan government now audits every single maternal death.

When women die from a cause related to pregnancy, health officials conduct an investigation and give a report to the president. The policy’s underlying premise is that mothers are not supposed to die. When they do, the government wants to know why.

Sri Lanka has cut its maternal mortality rate in half, and in half again, and again, every decade for the last 80 years.

Something very similar is happening in Malawi right now. Historically, Malawi has struggled with very high rates of maternal and child mortality. But in the past few years, the government has spurred a revolution in women’s and children’s health.

Using a network of well-trained frontline health workers, Malawi was one of the first countries in Africa to focus on the health of newborns. It also reaches almost 90 percent of children with standard immunizations.

As a result, it is one of the handful of countries on track to meet the Millennium Development Goal on child survival.

I traveled to Malawi in January, and the walls at the hospitals were covered with a poster that said, “No mother should die during childbirth.”  In Malawi, those words are more than just a public health message. They represent a commitment by the government to make sure that every mother gives birth in a health facility, cared for by trained medical staff.

When I was in Malawi, I had the pleasure of meeting with the President and Vice President, the architects of these successes for Malawian mothers and their babies.

Vice President Joyce Banda is in the hall today. Vice President Banda, will you please stand? You are living proof that women deliver.

Success stories like Sri Lanka and Malawi are generating more attention for our cause. More developing countries are passing pro-mother and pro-child policies. More developed countries are making women and children a foreign aid priority.

This groundswell of support puts the responsibility squarely on the shoulders of those of us in the global health community.

As governments increase their spending, they will ask us: “How should we spend this money? Which interventions are the most effective in our country? How do we scale them up?”

We need to be ready with answers.  We need to be ready with a plan. A single plan on which we all agree.

And that means we need to be much more coordinated than we have been. The global health community has gradually divided into factions that support a maternal strategy, or a child strategy, or a dozen other sub-strategies.

Like any professional field, global health naturally tends toward specialization. We focus on diseases and conditions, because it helps us develop expertise. The community working on women’s and children’s health has been organized that way for a very long time.

Specialization has certainly been the model at the Gates Foundation. Traditionally, we have broken down our strategies by disease.

But women and children aren’t preeclampsia or malnutrition or neonatal malaria. They aren’t emergency obstetric care or community-based care. They aren’t conditions or procedures or treatment models. They are human beings.

That is why the Gates Foundation is joining many others in the global health community in working toward a more integrated approach to women’s and children’s health. The goal is to design our work around the needs and wants of women and children, not around our own areas of expertise.

Caring for human beings is complex. The same woman who is nervous about giving birth is also desperate to feed her starving two-year-old.

Childbirth and proper nutrition may seem like discrete issues to us, but people don’t divide their lives into segments that way.  I have never met a woman whose dream for her children was that they would sleep under a bed net, or eat fortified maize flour.

The women I talk to want two things above all: They want their children to grow up healthy, and they want them to get a good education, so they can realize their full potential.

A woman’s first need is planning her family, and therefore it has to mark the beginning of the continuum of care.  When I talk to women in developing countries, one of the first things they bring up is their desire to plan the number and timing of their pregnancies.

As a woman, I can’t imagine being denied access to the tools I need to plan. It is my basic right to be able to choose when to have children.

When women have the right to make that choice, we are able to make other important choices in our lives – about where we want to live, what we want to do for a living, and who we want to marry. Why in the world should any woman be prevented from doing what’s best for her health and for the health of her children?

Yet, right now, more than 200 million women want to use contraceptives but don’t have access. If they did, their families would be healthier. Experts agree that fulfilling the unmet need for family planning would reduce maternal deaths by at least 30 percent, and newborn deaths by 20 percent.

In many countries, family planning has become a lightning rod for controversy. But it doesn’t have to be.

The essence of family planning is the fulfillment of a desire that all families have: to make a choice about when they want to have children. There are safe and effective tools that help a woman plan when to get pregnant, and when not to. It is reckless to prevent women from using them.

After family planning, the continuum of care includes prenatal care, safe childbirth, postnatal care, nutrition, and child health care, including immunization.

We don’t have to treat these as separate issues. We can treat them the way mothers themselves treat them – as equally essential parts of a single, overarching goal: giving their children a healthy start in life.

Another thing that’s hard about caring for human beings is that social and cultural factors influence how people behave in ways that aren’t always easy to understand.

This is especially true when it comes to childbirth, because childbirth is not just a medical procedure; it is also a rite of passage. It has everything to do with custom and ritual, and those are not areas where the global health community is particularly comfortable working.

We can say: “Making sure the umbilical cord is clean and dry prevents infection.” But there is so much we don’t know about spreading that message.  What prevents a mother in Uttar Pradesh from letting the cord dry? What is the best way to help her understand why she should? Can you use the same method for a mother in Malawi?

The science of behavior change has advanced a lot in the past few years, and it’s important that we keep pushing it forward.

I recently visited in an Indian village, where I saw a powerful example of this kind of work. The project, located in Shivgarh, is devoted to facilitating conversations in the community about simple techniques like skin-to-skin care that save lives.

Not a single tool used in the Shivgarh project was developed in a scientific laboratory. On the contrary, most are literally thousands of years old. It’s the way the tools are used that is so innovative.

Women sing songs about immediate and exclusive breastfeeding. Men and women act in plays that dramatize the importance of including husbands, mothers-in-law, and community leaders in planning for birth.

In Shivgarh, women learned to let the umbilical cord dry by making an analogy to their everyday life. They explained to each other: If you take two flat breads, or chapattis, and you put oil on one and nothing on the other, the one with oil will collect more dust and dirt than the one without.

By the same principle, if you don’t put oil or anything else on the umbilical cord, it is less likely to become infected.

The results of interventions like these have been astounding. In just 18 months, behavior change alone has cut neonatal mortality in Shivgarh by more than half. And new evidence indicates that these interventions saved the lives of mothers as well.

There are a handful of similar examples elsewhere in India and in several countries in sub-Saharan Africa. Now, we have to evaluate these successes so that they can be extended to other places.

Which strategies will help behavior change stick for generations? How can we adapt these village-level interventions for places where birthing practices are different? And how do we scale up effective behavior-change programs, so they can help tens of millions of people?

This is a pivotal moment for women’s and children’s health. This is our moment. We finally have the world’s attention.

The task ahead is to be ready to make the most of the opportunity we created – to do the hard work of saving women’s and children’s lives. We must move forward together, as one, with the courage to overcome the obstacles that have stopped us in the past.

Our unity and our courage will be tested in a few weeks’ time. When Canada hosts the G8 later this month, it will launch the most ambitious effort on behalf of women’s and children’s health in history. The biggest donors in the world will be looking to us for leadership.

A few weeks later, the United Nations will publish its Joint Action Plan, leading up to the special session on the Millennium Development Goals in September. The whole world will be looking to us for leadership.

For years, we have nurtured a vision of global health that embraces mothers and their babies. Now, the whole world sees what we see.

• In the world we see, we will be able to track exactly how much donor countries are spending on women and children. And they will be spending a lot more than they are now.
• In the world we see, developing countries will pay close attention to women’s and children’s health. They will pass rigorous policies, and fully fund their implementation. Health workers in every country will have the tools and training they need.
• In the world we see, our community will work together to gather solid evidence about the interventions that work best, and combine them into a comprehensive plan to save lives.
• In the world we see, women everywhere will have the knowledge and the power to save their lives, and the lives of their babies.

And so I’m thrilled to announce that the foundation will invest major new resources to help make this vision a reality.

Today, we are committing to make new grants totaling $1.5 billion over the next five years to support family planning, maternal and child health, and nutrition programs in developing countries.

This new pledge will complement our spending in other areas that affect women’s and children’s health, such as developing and delivering children’s vaccines, and preventing pneumonia, diarrhea, malaria, and HIV/AIDS.

I’m also making women’s and children’s health my personal priority as co-chair of the Gates Foundation.

My commitment to you is that I will continue to talk to leaders in rich countries about making funding pledges and following through on them.  I will continue to talk to leaders in poor countries about making women and children a policy priority.

We will continue having this conversation about the work we’re doing together. We hold the future in our hands.

And I am going to keep visiting mothers like Rukmini. For when she hugs her daughter Durga, she also holds the future in her hands.

We have the momentum now.

We are making a new world for poor women and children: a world in which every birth is a promise – a promise for a better future.