Offline: The Mexican revolution

Abstract

Ana Langer's choice of Mexico for last week's landmark Global Maternal Newborn Health Conference was inspired. Writing in The Lancet in 2006, Jaime Sepulveda identified reasons why his country had succeeded so spectacularly in reducing child mortality. Strong leadership. Ministers of Health who knew their subject. Continuity of policies between governments. Institutions that provided independent technical advice to ministers. A results-based culture. Between 1990 and 2015, child mortality in Mexico fell by almost three-quarters, newborn mortality by two-thirds, and maternal mortality by over a quarter. Mexico's message is that with the right leaders, the best evidence, skilled health professionals, and a demanding public, rapid (indeed historic) progress is possible. The Mexico maternal newborn conference made the surviving and flourishing mother and child the indissoluble unit of a civilised society. But five crucial tests must be passed if the collective hopes expressed in Mexico City are to be fully realised. First, understanding sustainable development. How does economic growth, rapid urbanisation, environmental degradation, conflict, and humanitarian emergencies, among other sustainable development goals, affect maternal and newborn health? These determinants must be addressed if the advances made for women and children are to be sustained. Second, defeating inequity. Human beings are programmed to prefer egalitarianism to inequity and inequality. It taps into the deepest rhythms of our evolutionary history. Perhaps this is part of the appeal of universal health coverage. Some argue that the maternal and newborn health community is a distracting lobby group in global health. But although integration into universal health coverage makes sense, the levels of injustice faced by women and children worldwide are so extreme, so pervasive, that they demand our attention beyond a commitment to universality. Third, making the prevention of stillbirths a central goal. “A child is irreplaceable. Parents grieve a lifetime”, said Jessica Ruidiaz. We know what to do. Break the taboo of silence. Count stillbirths. Honour the life of every stillborn child. Invest in midwives. We must attack and defeat this epidemic of grief. Fourth, prioritising sexual and reproductive health and rights, which still remains marginalised in discussions about maternal and newborn health—universal access to family planning, safe abortion, detection and treatment of sexually transmitted infections, and comprehensive sexuality education. Finally, strengthening accountability. Accountability enables us to learn from our successes and mistakes. Accountability holds governments to their commitments. Accountability holds donors to their promises. Accountability gives power back to citizens. Perhaps a further test was identified by Hans Rosling—factfulness, the idea that you should only have opinions for which you have evidence. He asked an audience of 1000 delegates in Mexico some simple questions. What is happening to the number of children worldwide? Most people said it was increasing. In fact, the long rise in numbers of children is coming to an abrupt end. Of every ten girls in the world, how many are in primary school? Most people voted for five or fewer. The true number is nine. What is the average life expectancy today? Two-thirds of the audience said 60 years. The actual answer is over 70. Rosling demonstrated that even among knowledgable people, we all have cognitive frailties. In this case, a global health audience saw the world in a much more negative light than it truly was. Rosling concluded, “The overall view of the world we have is wrong. The world is much more advanced.” That may be true. But as the meeting emphasised, there are still 2·6 million stillbirths each year, including 1·2 million intrapartum stillbirths—where a baby begins labour alive, but dies before birth. 43 countries had a higher number of maternal deaths in 2013 than they did in 1990 (Nigeria had an estimated 21 233 maternal deaths in 1990, but 36 698 in 2013). 17 nations had higher numbers of newborn deaths in 2015 than they did in 1990 (Democratic Republic of the Congo had an estimated 66 000 newborn deaths in 1990, compared with 94 000 in 2015). There are certainly successes to celebrate globally. But there are terrible failures too. Our understandable desire to prefer success over failure obscures the realities (and indignities) of life for hundreds of millions of mothers and newborns worldwide. Jennifer Bryce celebrated her retirement from Countdown to 2015 last week in Mexico City. Jennifer originated the idea of The Lancet's global health series, and her contribution to international child health is monumental. We wish her a long and happy time on her farm in New York State Jennifer Bryce celebrated her retirement from Countdown to 2015 last week in Mexico City. Jennifer originated the idea of The Lancet's global health series, and her contribution to international child health is monumental. We wish her a long and happy time on her farm in New York State