Strategies to Reduce Maternal Mortality Worldwide

Jerker Liljestrand, MD, PhD Principal Health Specialist Health, Nutrition and Population Human Development Network The World Bank 1818 H Street NW Washington DC 20433, USA Phone + 202 458 0198 Fax + 202 522 3234 jliljestrand@worldbank.org Abstract The challenge of reducing maternal mortality (MMR) is increasingly being addressed by area-based efforts to improve access to care of obstetric emergencies. Improving coverage and quality of skilled attendance at birth is also being increasingly emphasized. Post-abortion care, better reproductive health services for adolescents, and improved family planning care are important ingredients in MMR reduction. New developments in malaria, nutrition, violence and HIV/AIDS in relation to maternal health are highlighted, as well as measurement issues. MMR reduction is also being promoted today by using a human rights approach. Introduction While worldwide infant mortality and total fertility rates have been cut in half in recent decades, and life expectancy at birth has increased greatly, maternal mortality has shown no major reduction over a similar period [1]. After the publication of the now famous article Where is the M in MCH? [2], and the introduction of the Safe Motherhood Initiative in Nairobi in 1987, maternal mortality reduction has been getting more attention than previously. The heightened awareness of this long neglected tragedy [3] has led to increased commitment [4], more research on specific interventions, and critical assessment of the strategies used. The main challenge today is not the lack of knowledge of key, effective interventions to save mothers, but rather how to deliver these health care interventions to the poor and underserved. This article evaluates the recent developments in mortality reduction, starting with the intriguing topic of measurement issues, thereafter analyzing health system strategies - broader and more specific -, and ending by discussing maternal health care in its societal context including issues of violence and rights. Measuring maternal mortality The shocking reality of a woman dying in childbirth or from pregnancy-related causes is, even at its extreme levels, a rare event when compared to e.g. infant mortality rates (IMR). Without any

health care whatsoever, some 2% of women will die during their pregnancy due to complications. This figure is roughly 1/5 of IMR in the poorest countries. The confidence interval of any MMR estimate will therefore always be wider than for IMR, and this is further impacted by underreporting in all countries where it has been studied. Another feature is that MMR is expressed as maternal deaths/100,000 live born. Thus, even if the absolute number of maternal deaths decline due to fertility decline, MMR will remain the same if the risk for the woman, once pregnant, is unchanged. Life-time risk of maternal death expresses the risk for the individual woman to die a maternal death, and is derived from the MMR and the fertility rate in a given country. So how do we measure the problem, and how do we monitor progress? The various ways of measuring maternal mortality [5] all give a rough estimate of the MMR level. As precision is relatively weak, there is rarely reason to repeat the measurement more frequently than every 5-10 years. To monitor programs, it has been agreed to use access or uptake of essential obstetric care, case-fatality rate, and coverage of skilled attendance at birth [6]. Skilled attendance at birth was also in 1999 by the UN meeting following up on 5 years of progress of the International Conference on Population and Development (ICPD+5) set as a benchmark for the improvement of maternal health care [7]. To perform long-term studies of which sets of interventions are most effective something that in maternal health is both difficult and costly to perform - there is a need to follow projects with as much rigor as possible. Wardlaw and Maine

[8], and Campbell [9] have recently expanded on this, underlining the need for better obstetric record keeping, and more critical use of data for following projects. Campbell also emphasizes the overall need for use of a wider range of care and outcome indicators in descriptive studies, to be able to tease out what works and what does not. This is illustrated by recent work from Indonesia [10]. One important way of both assessing and improving maternal health care provision is by use of verbal autopsy detailed discussion with the family on the symptoms and evolution before death, leading to a tentative cause of death diagnosis - of community deaths [11] or clinical audit in health care [12]. Combining the two is labeled maternal death review and a WHO tool is available to perform such systematic exploration of a maternal death [13]. The results of such reviews increase understanding and fuels action both inside and outside the health care system. Broad strategies for MMR reduction During the 1990s, a major push towards focusing efforts specifically on the care of obstetric emergencies was led by a group of researchers from Columbia University, USA. A series of experiences based on the use of this approach in a series of West African countries was published recently [14], and the group in 1999 received a grant from the Bill and Melinda Gates foundation to implement similar work in additional countries. In brief, using the 3 delays model [15], intensive local efforts are made to make around the clock care of obstetric emergencies available at district hospital

level or equivalent, using the minimum requirements internationally agreed upon [6]. Another group, the Unmet Obstetrical Need Network (UON) [16], uses a participatory model to assess the unmet need for major obstetrical interventions on vital maternal indication in a defined area as a way of locally and nationally communicating the need for improved care of obstetric complications. A report on their progress in a dozen developing countries can be found on the web at www.uonn.org. In 1999, concern was raised regarding the appropriateness of the strategies of the Safe Motherhood Initiative: Why were the above area-based approaches focusing on obstetric emergencies not being used? Why were the interventions suggested so complicated [17, 18]? Part of the response is to be found in a recent Joint Statement from UN agencies [19] as well as in ICPD+5: yes, better care of obstetric emergencies is a must, but not enough. Increasing age at marriage/first birth, improving family planning, especially for adolescents, and addressing unsafe abortion are also necessary. Long term plans to improve the coverage and quality of skilled attendance at birth appears also to be key for substantial MMR reduction in the long term [20, 21]. The two approaches are not contradictory but rather supplementary. The operations research performed by the Columbia group has been crucial to inspire confidence in the fact that progress can be achieved in the short term. However, countries like Malaysia, Sri Lanka, Vietnam [22], the Gambia [23] and most recently Honduras (personal communication, I Danel) that have succeeded to diminish MMR levels have addressed a number of other points, too.

One analysis of the ways of organizing essential obstetric care in countries having reached MMR under 100/100 000, yielded four basic models of care [24]. In Model 1, deliveries were conducted at home by community member that had received a brief training, with back-up of a referral system. Although there have been some successes with this model, in China and in parts of Brazil, there is no evidence that MMR can be brought down under 100 per 100,000 live-births using this method. In Model 2, skilled attendance is provided at home births, and in Model 3, skilled attendance is given in a basic facility, in both models with back-up of referral systems. In Model 4, all women give birth in a facility with comprehensive obstetric services (which includes cesarean section etc). Model 4, though the most advanced, interestingly does not necessarily bring down MMR under 100/100,000 and is also out of reach for many poor countries. This leaves models 2 and 3. No clear data indicate which of these is most effective or cost-effective. Transition to any of models 2-4 requires strong links with the community through either traditional providers or popular demand. Overall, it is recognized that MMR reduction requires more and better health care, i.e. a stronger health system at all levels [25, 26, 27]. Maternal health can therefore be seen as a tracer condition for the health system, and improvements in maternal health care can be expected to benefit other conditions also, e.g., accident care, district hospital care or primary health care in general [28]. To improve maternal health care approaches, more health services research is needed [29].

As in all health care system areas, use of a continuous quality improvement methodology is important. Auditing routines as well as efforts to improve teamwork are examples of this [26, 27, 30]. In resource-poor countries in particular, traditional birth attendants (TBAs) can provide a link to formal maternal health care systems even if they themselves can only to a limited extent care for unexpected obstetric complications [31]. Based on evidence to date, there is no reason to believe that TBA training in isolation can contribute significantly to MMR reduction [19]. Specific strategies It is generally recognized today that antenatal care in itself can only to a limited extent reduce maternal mortality, while many of its interventions benefit health of the baby. A cohort study from Bangladesh underlines that detecting current complications is more important during antenatal care than finding high risk [32]. A recent multi-country study coordinated by WHO also shows that more than four visits is not useful for low-risk pregnancy, either for the mother or child [33]. Postpartum care is a neglected area [34] and should receive much more attention both in research and action as most maternal deaths in fact happen there. Elimination of abortion related deaths requires different interventions in policy and care provision, depending on the country situation [35]. For better postabortion care accepted by almost all countries at ICPD in Cairo 1994 community involvement is needed to

sensitize people and decision makers regarding the relative simplicity of saving lives [36]. The arrival of the cheap abortifacient misoprostol [37, 38] appears to already have changed the abortion panorama in many developing countries. Misoprostol given orally has also been recently compared to IM oxytocin for use for the routine, active management of the third stage of labor [39]. While the latter is still the drug of choice for this routine, and increasingly promoted by WHO [40], oral misoprostol appears to be a good alternative when unsafe injections is a problem. In eclampsia management, the access to and use of magnesium sulphate is fortunately gaining ground, and a WHO collaborative trial is ongoing to establish its role also in cases of severe preeclampsia. As regards nutritional interventions, vitamin A supplementation and anemia reduction have potential maternal benefits. The dramatic results seen in Nepal when supplementing pregnant women with vitamin A a 40 % reduction of MMR - [41] has still not been corroborated elsewhere, nor led to clear programmatic implications. Vitamin A deficiency is quite common and low-dose substitution is safe [42], and evidently vitamin A deficiency is a neglected area that increasingly must be addressed inside and outside maternal health care. Iron supplementation has been reviewed recently [43, 44], and is one important aspect of reduction of maternal anemia. Less anemia means reduced risk of dying from post partum hemorrhage, often the biggest killer. For anemia reduction, malaria prevention

and management in pregnancy must also be intensified in many developing countries. Where drug resistance and/or low compliance so indicates, single dose treatment with sulphadoxinepyrimethamine 2-3 times during pregnancy is now being recommended for 0- and 1-parae [45], and also supported by the WHO. This regimen reduces maternal anemia and low birth weight, but can only be expected to be effective for a limited number of years ahead, however as drug resistance develops fairly rapidly. One major threat to maternal health, and infant health, is the rapidly evolving AIDS epidemic. Any strategy for maternal mortality reduction in Subsaharan Africa or South Asia today needs to take the rapidly evolving pandemic into account. In countries such as South Africa and Zambia [46], AIDS and related complications already contribute significantly to indirect causes of maternal death. Multisectoral approaches and NGO involvement must be directed towards a few clear and generally accepted goals to be effective in mitigating this major developmental crisis that is threatening to eliminate decades of hard-won victories in health [47]. In maternal health care, it is important to capitalize on existing work, by collaborating between MMR and HIV reduction strategies [48]. Human rights issues Maternal mortality is associated with womens status and economic dependency [49]. Decisive interventions, such as skilled attendance at birth, are in fact significantly more inequitably distributed than antenatal care or child immunization (personal communication,

DR Gwatkin). Poverty is thus a major contributory factor behind maternal deaths, and providing maternal health care is a necessary component of poverty alleviation strategies. In recent years, maternal health has increasingly been promoted using a human rights perspective. If a certain frequency of potentially lethal complications always will occur in the process of human procreation, specifically during pregnancy and childbirth, why do we permit the continuation of such a tragedy? Recent work highlights how human rights arguments can be used to make governments increase access and coverage of maternal health care provision [50]. Evidently much remains to be done in this and other areas of implementing the Cairo agenda on reproductive health, however [51, 52]. Human rights are also at the center of the abortion issue, where some progress can be seen internationally in recent years, in the legalization and de-penalization of induced abortions to save womens lives [53, 54]. A key issue is also the provision of youth friendly reproductive health services to young people [55], including counseling and care on contraception, STDs and pregnancy. Another aspect of rights issues concerns violence against women. An increasing body of evidence indicates that many negative maternal and perinatal health outcomes are linked to discrimination, coercion and violence against women. International studies have shown that as many as one out of four women are physically or sexually assaulted during pregnancy, most frequently by their husbands or intimate partners. Violence during pregnancy can lead to such

serious consequences as infections, unsafe abortions, miscarriages, low birth weight, suicide and homicide. Therefore, efforts to address gender-based violence must be included in a global strategy for reducing maternal mortality. [56]. Overall, actions and research on more involvement of men in maternal health stands out as important. Conclusion Reducing maternal mortality requires strengthening of the health care system. This process takes time, and must be fueled by public commitment sustained by, e.g., maternal death reviews. One valuable entry point is the improvement of care of obstetric emergencies, but skilled attendance at birth in general also demands long term planning. Newer technical interventions need to be integrated into existing systems, while AIDS poses an increasing threat. The attention and care given to women before, during and after pregnancy, inside and outside the health system, reflects the relative value a society accords to women References 1. Liljestrand J. Reducing perinatal and maternal mortality in the world: the major challenges. Br J Obstet Gynaecol 1999; 106:877-880. 2. Rosenfield A, Maine D. Maternal mortality a neglected tragedy. Where is the M in MCH? Lancet 1985; 2:83-85. 3. Graham W. The scandal of the century. Br J Obstet Gynaecol 1998;105:375-376.

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* A comprehensive overview of the issues involved. 36. Baird TL, Billings DL, Demuyakor B.. Community education efforts enhance postabortion care program in Ghana. Am J Publ Hlth 2000;70(4):63162. * * A good field example of strengthening post abortion care. 37. Carbonell JL, Varela L, Velazco A et al. Vaginal misprostol for abortion at 1013 weeks gestation. Eur J Contracept Reprod Health Care 1999 4;1:35-40. 38. Scheepers HV van Erp EJ, van den Bergh AS. Use of misoprostol for first and second trimester abortion: a review. Obstet Gynecol Surv 1999; 54:9 592600.* * Misoprostol is rapidly gaining ground for abortion in developing countries, and this is a good overview of the drug. 39. Villar J, Gulemezoglu AM et al. The WHO multicentre double-blind randomized controlled trial to evaluate the use of misoprostol in the management of the third stage of labour. Accepted. 40. Gulmezoglu AM. Prostaglandins for prevention of postpartum haemorrhage. Cochrane Database Syst Rev 2000;2:CD000494.* * Highlights the need for much more active promotion of active management of third stage of labor everywhere in health care, in developed and developing countries. 41. West KP, Katz J, Khatry SK et al. Double blind, cluster randomized trial of low dose supplementation with vitamin A or carotene on mortality related to

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