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 under-served.
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 costeffective. 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 post-abortion 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 sulphadoxine-pyrimethamine 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 Sub-saharan 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 women’s 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 women’s 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
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