Maternal health in the developing world

A new report from UNICEF—State of the World's Children, highlights the vast inequality that exists across the globe in maternal and infant healthcare. While improvements in healthcare and technology in parts of the world have greatly decreased the risks associated with child-bearing, much of the world is not benefiting from these improvements.

The report states that "more than half a million women die from causes relating to pregnancy and childbirth, and nearly 4 million newborns die within 28 days of birth" every year. The vast majority of these deaths could be prevented if maternal and healthcare services that are benchmark standards in countries like New Zealand existed across the globe. According to the report, the discrepancies between the health outcomes for women in the developed world and those in Sub-Saharan Africa or South Asia are immense. A woman living in Ireland has a 1 in 47,600 chance of dying as a result of pregnancy and childbirth, compared to a woman from Niger who has a 1 in 7 chance. A further multitude of women incur severe injuries or disabilities like obstetric fistula or anaemia as a result of their pregnancies. Similarly, the vast majority of children who die before the age of five are from the developing world, with Africa and Asia experiencing 92 percent of these deaths in 2007.

There is no single reason for high rates of maternal and infant mortality in the developing world. The three major causes of newborn deaths are "severe infections—including sepsis/pneumonia, tetanus and diarrhoea—asphyxia and preterm births." Underlying these are a multitude of secondary factors. Infections are more common when hygiene is poor and education is lacking, preterm births are more common in regions affected by malaria, and asphyxia is easily curbed by improved care during labour—this is difficult to attain in areas where infrastructure is poor. The report suggests that those who are in countries with poor governance, instability or no rule of law, termed "fragile states," are in particular need as services cannot be delivered reliably to citizens and maternal healthcare is inconsistent. Given the complexity of these multiple factors, State of the World's Children argues for integrated healthcare along with long-term development work, suggesting this combination is crucial for bringing about change in the worst-affected regions.

Humans have flown to the moon and kayaked across the Tasman, but women still die giving birth because of poor medical care. The report is alarming in what it reveals about the state of the globe and the conditions that many lives are birthed into. Yet it also speaks of a number of places in which proactive efforts have begun to make a significant difference to mortality rates. In Mali, grandmothers have been involved in community education regarding nutrition, which is making a significant impact. Peru's Ministry of Health has recognised that cultural barriers prevent some women from utilising health services, and so has strategised a way to adapt maternity services to accommodate cultural traditions like giving birth at home. The experience of these countries seems to indicate that strategic, integrated approaches to development do have the potential to effect lasting change.

• Read State of the World's Children

Working for New Zealand?

The Human Rights Review Tribunal recently decided that in-work tax credits, which put money in the pockets of working parents with children, do not breach New Zealand's human rights laws. These credits are an integral part of the Working for Families package, and although the Tribunal found that they do discriminate against those who are not in work, it concluded that this discrimination is justified by a need to incentivise people to move off benefits and into work. However, the Tribunal questioned aspects of the scheme, expressing "significant reservations" about changes in 2005 that extended the tax credits to middle- and upper-income earners.

The case was initiated by the Child Poverty Action Group. Its main complaint was that families where the parents are beneficiaries are discriminated against because they are not eligible for in-work tax credits, while working parents are. Because the complaint was about the requirement to be in work, the Tribunal was not strictly being asked to decide whether it is appropriate that middle- to high-income earners receive the credit. Nevertheless, the Tribunal scrutinised this issue very closely, and took the opportunity to identify its concerns.

The Tribunal found that, as originally designed, the in-work tax credit was largely directed to low- and middle-income earners. For example, a one-child family could earn up to $39,500 and receive the credits. However, in 2005 changes were made so that by 2007 a one-child family could earn up to $71,000 and still receive the credits. Proportionate changes were also made for families with more children. OECD experts giving evidence to the Tribunal were not supportive of these changes, saying that "it means that a lot of money goes to people for reasons that cannot really be defended as an anti-poverty strategy. Nor do people at higher income levels need a payment of this kind to encourage them to stay in their jobs." The Tribunal agreed with evidence from another expert witness that "the tax credits start to become tax relief (as opposed to work incentive) at about $45,000 per annum and above."

The Tribunal's concerns are similar to those raised last year in our tax discussion paper, Is it Just Tax? where we pointed out that elements of the Working for Families package give financial assistance to those who are not in real need. As the Tribunal rather damningly stated, "The decision to extend the [in-work] tax credits had more to do with politics than policy." It remains to be seen whether the Tribunal's concerns get the reception they deserve. Combined with other concerns, including queries about the effectiveness of the work incentives, "poverty traps" and "marriage penalties," we should be asking whether Working for Families is working for New Zealand.

• Read the Tribunal's decision in Child Poverty Action Group Inc v Attorney- General
• Read Is it Just Tax? The shaping of our society

Feet on the ground

History was made this week, as Barack Obama was sworn in as President of the United States, the first Democrat since Bill Clinton and the first African- American President ever. In a series of addresses around Inauguration Day, President Obama set out his vision, calling for "renewal," unity, a willingness to uphold the traditional ideals of the United States and for action with "restraint and humility."

The prospect of an African-American as President has caused deserved celebration throughout the world. The new President possesses great stores of grace, decency and huge talent. His call to public service and his commitment to American ideals have the capacity to inspire not just citizens of the United States, but the whole world with a vision of power committed to servanthood, where politics is part of a noble, and achievable, dream.

President Obama's inaugural address contains tastes of the soaring rhetoric he has become noted for, and an appeal to, in his words, move away from "the stale political arguments" of the past. He argues, "The question we ask today is not whether our government is too big or too small, but whether it works—whether it helps families find jobs at a decent wage, care they can afford, a retirement that is dignified. Where the answer is yes, we intend to move forward. Where the answer is no, programs will end."

This commitment to prudence is welcome. He is right to urge all Americans, and the whole world, to pull together through the storms ahead. But a commitment to pragmatism, while in some contexts useful, can mask the fact that all politicians necessarily make assumptions about human society, human nature and what they believe to be good. These assumptions inevitably have concrete policy outcomes. Responsible political partisanship is a reflection of the fact that differing views on issues like taxation, the role of government and our values really matter—they are not "stale" at all. It is possible President Obama really will bring "change we can believe in." It is also possible that an Obama presidency will simply baptise big government liberalism by another name. President Obama's commitment to "old" American values like "hard work" and "a spirit of service," his call for "humility and restraint" are best served by a bracing realism about the abilities of government, foreign policy and society. The most welcome elements in the speech are those which balance vision for the stars with keeping our feet firmly on the ground. In turbulent times, President Obama will need every ounce of sober judgement to steady the ship, and the good wishes of the whole world in the attempt.

• Read President Obama's Inaugural Address