strategies to reduce mmr

7/28/2019 Strategies to Reduce MMR

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Strategies to Reduce Maternal Mortality Worldwide

Jerker Liljestrand, MD, PhD

Principal Health Specialist

Health, Nutrition and Population

Human Development NetworkThe World Bank

1818 H Street NWWashington DC 20433, USA

Phone + 202 458 0198

Fax + 202 522 [email protected]

Abstract

The challenge of reducing maternal mortality (MMR) is increasingly being addressed by

area-based efforts to improve access to care of obstetric emergencies. Improvingcoverage 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 halfin recent decades, and life expectancy at

birth has increased greatly, maternal

mortality has shown no major reductionover 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 thanpreviously. The heightened awareness of

this long neglected tragedy [3] has led toincreased 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 ratherhow 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 andmore 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, arare event when compared to e.g. infant

mortality rates (IMR). Without any


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health care whatsoever, some 2% of

women will die during their pregnancy

due to complications. This figure isroughly 1/5 of IMR in the poorest

countries. The confidence interval of any

MMR estimate will therefore always bewider 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 dueto 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 forthe individual woman to die a maternal

death, and is derived from the MMR andthe 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 isrelatively weak, there is rarely reason to

repeat the measurement more frequently

than every 5-10 years. To monitorprograms, it has been agreed to use

access or uptake of essential obstetric

care, case-fatality rate, and coverage ofskilled 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 InternationalConference on Population and

Development (ICPD+5) set as a

benchmark for the improvement ofmaternal 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, andmore critical use of data for following

projects. Campbell also emphasizes the

overall need for use of a wider range ofcare and outcome indicators in

descriptive studies, to be able to tease

out what works and what does not. Thisis illustrated by recent work from

Indonesia [10].

One important way of both assessing andimproving maternal health care

provision is by use of verbal autopsy

detailed discussion with the family on

the symptoms and evolution beforedeath, 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 isavailable to perform such systematic

exploration of a maternal death [13]. The

results of such reviews increase

understanding and fuels action bothinside and outside the health care

system.

Broad strategies for MMR reduction

During the 1990s, a major push towardsfocusing efforts specifically on the care

of obstetric emergencies was led by a

group of researchers from Columbia

University, USA. A series of experiencesbased on the use of this approach in a

series of West African countries was

published recently [14], and the group in1999 received a grant from the Bill and

Melinda Gates foundation to implement

similar work in additional countries. Inbrief, using the 3 delays model [15],

intensive local efforts are made to make

around the clock care of obstetric

emergencies available at district hospital


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level or equivalent, using the minimum

requirements internationally agreed upon

[6]. Another group, the UnmetObstetrical Need Network (UON) [16],

uses a participatory model to assess the

unmet need for major obstetricalinterventions on vital maternal indication

in a defined area as a way of locally and

nationally communicating the need forimproved 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: Whywere the above area-based approaches

focusing on obstetric emergencies notbeing used? Why were the interventions

suggested so complicated [17, 18]? Part

of the response is to be found in a recentJoint 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/firstbirth, improving family planning,

especially for adolescents, and

addressing unsafe abortion are alsonecessary. Long term plans to improve

the coverage and quality of skilled

attendance at birth appears also to be keyfor substantial MMR reduction in the

long term [20, 21]. The two approaches

are not contradictory but rather

supplementary. The operations researchperformed by the Columbia group has

been crucial to inspire confidence in the

fact that progress can be achieved in theshort term. However, countries like

Malaysia, Sri Lanka, Vietnam [22], the

Gambia [23] and most recentlyHonduras (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 countrieshaving reached MMR under 100/100

000, yielded four basic models of care

[24]. In Model 1, deliveries wereconducted at home by community

member that had received a brief

training, with back-up of a referralsystem. 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 under100 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 basicfacility, in both models with back-up of

referral systems. In Model 4, all womengive 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. Thisleaves models 2 and 3. No clear data

indicate which of these is most effective

or cost-effective. Transition to any ofmodels 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 alllevels [25, 26, 27]. Maternal health can

therefore be seen as a tracer condition

for the health system, and improvementsin maternal health care can be expected

to benefit other conditions also, e.g.,

accident care, district hospital care orprimary health care in general [28]. To

improve maternal health care

approaches, more health services

research is needed [29].


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As in all health care system areas, use of

a continuous quality improvementmethodology 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 forunexpected obstetric complications [31].

Based on evidence to date, there is no

reason to believe that TBA training in

isolation can contribute significantly toMMR reduction [19].

Specific strategies

It is generally recognized today thatantenatal 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 fromBangladesh underlines that detecting

current complications is more important

during antenatal care than finding highrisk [32]. A recent multi-country study

coordinated by WHO also shows that

more than four visits is not useful forlow-risk pregnancy, either for the mother

or child [33]. Postpartum care is a

neglected area [34] and should receive

much more attention both in researchand action as most maternal deaths in

fact happen there.

Elimination of abortion related deaths

requires different interventions in policy

and care provision, depending on thecountry 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 thecheap abortifacient misoprostol [37, 38]

appears to already have changed the

abortion panorama in many developingcountries.

Misoprostol given orally has also beenrecently 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 thisroutine, 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 toand use of magnesium sulphate is

fortunately gaining ground, and a WHO

collaborative trial is ongoing to establishits 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 inNepal when supplementing pregnant

women with vitamin A a 40 %

reduction of MMR - [41] has still notbeen 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 maternalhealth care. Iron supplementation has

been reviewed recently [43, 44], and is

one important aspect of reduction ofmaternal anemia. Less anemia means

reduced risk of dying from post partum

hemorrhage, often the biggest killer. For

anemia reduction, malaria prevention


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and management in pregnancy must also

be intensified in many developing

countries. Where drug resistance and/orlow compliance so indicates, single dose

treatment with sulphadoxine-

pyrimethamine 2-3 times duringpregnancy is now being recommended

for 0- and 1-parae [45], and also

supported by the WHO. This regimenreduces maternal anemia and low birth

weight, but can only be expected to be

effective for a limited number of years

ahead, however as drug resistancedevelops fairly rapidly.

One major threat to maternal health, and

infant health, is the rapidly evolvingAIDS 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 suchas South Africa and Zambia [46], AIDS

and related complications already

contribute significantly to indirect causes

of maternal death. Multisectoralapproaches and NGO involvement must

be directed towards a few clear and

generally accepted goals to be effectivein 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 healthcare is a necessary component of poverty

alleviation strategies.

In recent years, maternal health has

increasingly been promoted using a

human rights perspective. If a certainfrequency of potentially lethal

complications always will occur in the

process of human procreation,

specifically during pregnancy andchildbirth, why do we permit the

continuation of such a tragedy? Recent

work highlights how human rights

arguments can be used to makegovernments increase access and

coverage of maternal health careprovision [50]. Evidently much remains

to be done in this and other areas of

implementing the Cairo agenda onreproductive 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, inthe legalization and de-penalization of

induced abortions to save womens lives

[53, 54]. A key issue is also the provisionof 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 increasingbody 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 arephysically or sexually assaulted during

pregnancy, most frequently by their

husbands or intimate partners. Violence

during pregnancy can lead to such


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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 requiresstrengthening of the health care system.

This process takes time, and must be

fueled by public commitment sustained

by, e.g., maternal death reviews. Onevaluable entry point is the improvement

of care of obstetric emergencies, butskilled attendance at birth in general also

demands long term planning. Newer

technical interventions need to beintegrated 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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health care approaches in an area are

unfortunately rare and costly. This oneshows the value of skilled attendance.

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** Full review on what is known onvalue of skilled attendance at birth.

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UNFPA, New York, 1999, Vol. 18.

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The World Bank. Lessons from 10 Years

of Experience. Thew World Bank,Washington DC, 1999.*

* This analysis shows that the World

Bank should invest in more coherentmaternal health programs.

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K. The role of health services research

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Publ Health 2000; 90(5):810-811.*

*Succinct overview of needs for healthservice research in maternal health.

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maternities in Morocco: how to motivate

professionals? Sante Publique1999;11(2):211-23.

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* A good study showing the limitations

of the risk approach (emphasized for so

long previously).

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new model of routine antenatal care: theWHO Antenatal Care Randomized

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** Ambitious multi-country study shows

the limited value of many antenatal

visits.

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* A comprehensive overview of the

issues involved.

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B.. Community education efforts

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62. *

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debated in the past years. This andprevious article remind us of what is

known.

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* Unfortunately malaria programs and

maternal health care programs do notalways work well together. New malaria

guidelines need rapid incorporating and

adapting at country level. Here one ofthe original studies showing value of

intermittent Fansidar.

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University Teaching Hospital in Lusaka,

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1999; 3 (8):675-80.** One of several recent reports from

Subsaharan Africa on rapidly increasing

burden of HIV/AIDS complications in

maternal health care.


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47. Ainsworth M, Teokul W. Breaking

the silence: setting realistic priorities forAIDS control in less-developed

countries. Lancet 2000;356:55-60.**

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developing countries, also drawing from

the relative success in Thailand.

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opportunity: collaborative initiatives to

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mortality, womens status, and economicdependency in less developed countries:

a cross-national analysis. Soc Sci Med1999;49:197-214.*

* A good multi-country analysis

reminding maternal health careprofessionals to look outside the medical

field.

50. Yamin AE, Maine DP. Maternalmortality as a human rights issue:

measuring compliance with international

treaty obligations. Human RightsQuarterly;1999;21:563-607.*

* Legal/human rights article giving

material for NGOs and nationalcommittees to enforce work from a

human rights perspective.

51. Catino J. Meeting the Cairochallenge: progress in sexual and

reproductive health. (Implementing the

ICPD Programme of Action). FamilyCare International, New York, October

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Reproductive health policies and

programs in eight countries: progresssince Cairo. Int Family Planning

Perspectives 1999;25(suppl):S2-S6.

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global review of progress. Issues in

abortion care 5. IPAS, Chapel Hill, 1999.*

* One of many useful contributions from

IPAS on the reduction of abortion-

related mortality.

54. Cook RJ, Dickens BM, Bliss LE.

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law from 1988 to 1998. Am J Publhealth 1999;89 (4):579-86.

55. Okonufua F. Adolescent reproductive

health in Africa: Future challenges.

African Journal of reproductive health2000;4 (1):7-9.*

* Good summary of the tremendous

challenge of improving RH conditions

for adolescents. The African situation isespecially acute due to the HIV/AIDS

crisis.

56. Heise L, Ellsberg M, Gottemoeller

M. Ending violence against women.

Population Reports, Series L, Number11. Baltimore, John Hopkins University

School of Public Health, Population

Information Program, 1999. **

** Excellent review of a recentlysurfaced problem, reader-friendly in

Population Reports series. Links

between maternal health and violencewell reviewed. Text available on the web

at www.jhuccp.org.

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