The Lancet

According to results of the US Centers for Disease Control's analysis of mortality data from the National Vital Statistics System, the age-adjusted suicide rate per 100 000 population aged 35–64 years in the USA increased by 28·4%, from 13·7 in 1999, to 17·6 in 2010. The highest increase (65·2%) was in American Indian and Alaska Natives, from 11·2 to 18·5.

The theme for today's Lancet is the third Women Deliver conference in Kuala Lumpur, Malaysia on May 28–30. To document progress, barriers, and opportunities in reproductive, maternal, newborn, and child health, the journal's research section has been expanded to accommodate six studies; more will be published online. The studies use different methods to show the multidimensional nature of reproductive health and the influence of social determinants and health systems. Kuala Lumpur is an inspiring venue.

The news had been long awaited. Since their approval, health experts and campaigners, including The Lancet, have called for the vaccines against the human papillomaviruses (HPV) that cause cervical cancer to become available at a much cheaper price.

Nearly half of Americans who test positive for hepatitis C virus (HCV) infection with an initial antibody test do not receive the follow-up RNA testing that is necessary to show whether they have recovered or have an ongoing infection. If left untreated, ongoing infection could lead to serious liver disease and death. This worrying finding comes from a new study by the US Centers for Disease Control and Prevention (CDC). In about 20% of cases, the body clears HCV infection unaided, but most people need treatment—typically pegylated interferon and ribavirin.

When we consider global health issues, we often group nations and regions by categories such as developed or developing. Although these categorisations are useful in particular circumstances, sometimes they obscure the fact that all of us throughout the world—especially women—face shared challenges. A close look at the issues surrounding maternal health shows clearly that we in the USA also have substantial progress to make.

The third Women Deliver conference, on May 28–30, 2013, in Kuala Lumpur, Malaysia, marks a new chapter for maternal health in Malaysia and worldwide. We have witnessed national maternal mortality rates in Malaysia decrease from 540 per 100 000 livebirths in 1957 to just 28 in 2010. The percentage of women delivering in national institutional settings rose from 10% in 1957 to 98·7% in 2005. We hope that Malaysia's successes and the struggles that we continue to face will be useful to countries working to improve maternal and reproductive health.

Millennium Development Goal 5 sets the ambitious goal of a 75% reduction in maternal mortality worldwide by 2015. Although some progress has been made, the risks from childbearing remain unacceptably high: an estimated 287 000 maternal deaths occurred in 2010, almost all of which were in developing countries. Moreover, maternal deaths are just the tip of the iceberg—millions more women suffer adverse health consequences from childbirth. Although medical solutions do exist, increased government attention is needed to implement policies and programmes to improve the supply of, and demand for, services.

Conventional thinking behind global efforts to prevent the deaths of mothers and children younger than 5 years starts with the identification of an intervention with a clear biological pathway for reducing morbidity and mortality, such as a drug, vaccine, micronutrient, or health-related behaviour. The efficacy of this intervention is then tested in randomised trials, followed by meta-analyses of the trials' findings. If results are encouraging, the intervention is scaled up, most frequently by integration with existing delivery platforms such as facility or community-based health services, or mass campaigns.

The notion that severe maternal outcomes (SMOs) should be reduced by the essential interventions (eg, prophylactic or therapeutic uterotonic and magnesium sulphate for eclampsia) that have been promoted extensively in the past 10 years by various UN agencies is widely accepted. However, quantification of rates of SMO around the world is challenging because of different definitions in use. In the WHO Multicountry Survey on Maternal and Newborn Health, published in The Lancet, João Paulo Souza and colleagues have produced a definition of SMO, including near-miss events, and have undertaken a large international survey to assess the effects of essential interventions on maternal outcomes.

The rebirth of family planning is well underway and could not be more important or timely, as countries worldwide work towards implementation of international human rights agreements and achievement of the Millennium Development Goals. and, in this issue, by Jacqueline Darroch and Susheela Singh, unmet need for modern contraception in the world's poorest countries is still unacceptably high. Meeting this need will not only help individuals and couples to gain the right to contraceptive information and services, but will also improve the health of women, children, and families.

In the past 30 years, reduction of maternal mortality has been a prominent focus in global public health. Improvements in women's reproductive health and antenatal and obstetric services mean that Millennium Development Goal 5 (target A of which aims to reduce maternal mortality by 75% between 1990 and 2015) has come within sight in many countries, most notably in Latin America and Asia. Yet across sub-Saharan Africa, maternal mortality has been an intractable problem. More than 50% of all maternal deaths occur in Africa, and the maternal mortality ratio in sub-Saharan Africa is more than double the global average.

As the 2015 deadline for the Millennium Development Goals (MDGs) approaches, MDG 5—to reduce maternal mortality and achieve universal access to reproductive health—has shown the least progress of all the goals. This low progress is clearly a major concern in view of the worldwide morbidity and mortality caused by poor access to reproductive health care. Investment in reproductive health care is not only cost effective in improving health outcomes, but is also one of the most effective ways to promote equitable and sustainable development and to break the cycle of intergenerational poverty.

More than 2 million girls and women in developing countries are living with obstetric fistula, a condition that has been virtually eliminated in the industrialised world. Obstetric fistula results from prolonged obstructed labour in the absence of emergency medical interventions, notably caesarean section. The incontinence that ensues can lead to marginalisation and a range of psychological, social, economic, and physical vulnerabilities. Many women and girls with fistula find themselves trapped in poverty because they are excluded from community life, denied livelihood opportunities, and abandoned by their husbands and families.

The first meeting of a new Commission on the Future of Health in Africa, led by Peter Piot (Director of the London School of Hygiene and Tropical Medicine), met last week in Ghana's capital city, Accra. The last Commission for Africa, produced for the G8 Summit held at Gleneagles in 2005, received mixed reviews. Bob Geldof called Tony Blair's Commission “a triumph for Africa”. But its longer term impact is contested. The vision for Africa in 2005 was of a continent in the midst of a crisis: the Commission's opening line was “African poverty and stagnation is the greatest tragedy of our time”.

Evaluation of interventions to reduce the risk of maternal, newborn, or child mortality in sub-Saharan Africa is a priority because of the lack of progress towards the Millennium Development Goals (MDGs) and the high burden of newborn, infant, and maternal deaths borne by this region.

There are few signs of women's health improving in Egypt under the Muslim Brotherhood's rule, with some observers fearing a worsening of rights and attitudes. Sharmila Devi reports.

Health workers are awaiting the outcome of a Supreme Court hearing, which will decide if the Philippines can finally implement comprehensive reproductive health services. Yu-Tzu Chiu reports.

Nigerian officials hope that new measures to improve health care for women will bring down the country's high maternal mortality rate. Wairagala Wakabi reports.

The camera pans close to Destaye's young face as she flicks through her school notebooks, revealing densely handwritten scrawls on chemistry, geography, and history. She wanted to be a doctor in Ethiopia. Instead, she got married at 11 years old. “I felt ashamed that day”, she says. Watching Too Young to Wed: Destaye, it's hard not to think that it is her husband, a priest, who should be ashamed. “I didn't want a girl who had finished school. Girls who finish school might not stay virgins.”