“I would like for you to dream with me, to dream of a world where social justice is taken seriously.”

Michael Marmot

Reflecting on an umbrella term for social inequities in health leads to two all-embracing principles being assumed; the first is that not all forms of inequality found in health are included in its definition but only those being labelled inequity as they arise from inequality which is avoidable, unnecessary and unjust.¹ The second is related to that known as social inequality which describes inequity as being a consequence or product of situations which society can avoid.^2,3 The panorama for analysis thus ranges from what is very general, which would be health inequality, to something more specific such as social inequity in health in which society, the decisionmaker, and health care in the social security system must bear high levels of responsibility.

If the term is centred even more so on social inequity regarding maternal health, then the topic acquires dimensions having high social relevance as maternal health, or rather safe maternity, forms a fundamental part of the Millennium Development Goals and the public policy being promoted by the World Health Organisation and thus respective ministries in countries around the world.^4-10

The World Health Organisation stated as long ago as 1946 in its constitution that, “the enjoyment of the highest standards in health must be within everyone’s reach, without distinction of race, religion, political beliefs, economic or social condition”.¹¹ However, maternal mortality represents the greatest health inequity around the world, 99% occurring in so-called developing countries.¹² This means that the goals proposed since 1946 have not been achieved in maternal health and, perhaps, distances have become much greater and thus inequity has increased in all countries around the world.

Medicine has made its contribution to maternal health by improving the technologies being offered to mothers to ensure that their period of maternity becomes safer (safe motherhood programmes). This has led to the United nations Population Fund (UnFPA) proposing a three-pronged strategy for reducing maternal mortality by 75%; it consists of having access to contraceptive means and avoiding unwanted pregnancy, having access to health care provided by trained personnel when giving birth and that there is opportune access to emergency obstetric care when complications arise.¹³ However, such approach is centred on the model of attention as a strategy for reducing maternal mortality without understanding that there is a social and historical context behind women’s health directly or indirectly influencing the presentation of such unwanted health events.

This is where it becomes relevant to focus discussion on social inequity regarding maternal health and not the social inequity involved in providing maternal attention. The latter approach has overtones of providing health services whilst the former emphasises society, its setting and responsibility. The approach involving social determinants of health has thus been taken, even though providing health services is much easier for decision-makers from a practical point of view.

The fact that providing health services for mothers is dreadful in Afghanistan, Bangladesh, the Democratic Republic of the Congo, Ethiopia, India and nigeria should favour such approach as these countries are where half the maternal deaths occur around the world;¹² this means that worldwide inequity in health attention is extremely relevant. Likewise, when comparing the levels of poverty, gender inequity, overall inequity, illiteracy, educational level and development, then the data for these countries come within those having the worst figures around the world.¹⁴

In the world, Colombia and Colombian departments and municipalities regard maternal mortality as a high-priority public-health entity. Decision-makers, doctors and even families hope for the arrival of a life-saving intervention which would reduce all those avoidable maternal deaths which keep occurring, day after day and year after year, just by its effect and power. This would be ideal: a single-cause solution to a multi-cause problem. The reality is that safe motherhood ranges from good quality in providing health services to (lying behind other causes) the causes of the causes which Marmot talks about,¹⁵ implying a multimodal solution or intervention having many approaches at different hierarchical levels, including health attention as one of them, or dreaming a little, real organisation of the world to make it fairer, having less gaps between rich and poor, having greater access to development for all, higher educational levels (and access to education), less global inequity and less health inequity for both mothers and the general population.

Javier Eslava-Schmalbach, M.D., M.Sc., Ph.D.

Director of the Clinical Research Institute, Universidad nacional de Colombia

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