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Tracking changes in maternal mortality in developing countries can be difficult, because the data are unreliable. Vital-registration systems in rural areas of most developing countries are deficient, and surveys produce estimates with wide margins of uncertainty. By all accounts, however, progress in reducing maternal mortality has been very slow. The vast majority of maternal deaths are due to direct obstetrical complications, including hemorrhage, infection, eclampsia, obstructed labor, and unsafe abortion. An estimated 500,000 or more women still die each year from complications of pregnancy and childbirth, 95% of them in Africa and Asia.2 A comparison of the level of risk in various regions reveals glaring disparities (see table). The lifetime risk of dying during pregnancy is 1 in 16 in sub-Saharan Africa, as compared with 1 in 2800 in developed regions. This differential is one of the widest among indicators of public health status. Wide disparities in maternal mortality also exist within countries, often in association with differences in wealth or other dimensions of social advantage.
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Unfortunately, the Safe Motherhood Initiative initially took a few strategic missteps. Emphasis was placed on antenatal care, including screening for risk factors, and on training traditional birth attendants to use safe, hygienic practices. Neither approach had any real effect on maternal mortality. Many obstetrical complications cannot be predicted or prevented. Screening can identify women with certain risk factors (e.g., young age or high parity), but the majority of obstetrical complications occur in women categorized as having low risk. Although most deliveries in high-mortality settings take place at home, often with traditional birth attendants present, there is little that even trained traditional birth attendants can do by themselves to save women's lives when serious complications develop.
Today, strategies are more appropriately focused. It is essential that pregnant women in whom complications develop have access to the medical interventions of emergency obstetrical care. Programs to make such care more widely available involve upgrading rural health centers and referral hospitals and stocking them with the necessary drugs, supplies, and equipment, such as magnesium sulfate for eclampsia, antibiotics for infection, and basic surgical equipment for cesarean sections. Efforts also include training cadres of health care workers and developing strong referral systems between communities and health care facilities, since delays in care can be life-threatening. A referral system includes means of communication and transport as well as mechanisms for ensuring that referral facilities are able to provide services at all hours. When a functioning health care system is in place, some interventions at the community level, such as the use of misoprostol to strengthen contractions, help expel the placenta, and control bleeding before transfer to a health care facility, could contribute to significant reductions in maternal mortality.
An effort is also under way to ensure that all pregnant women have a skilled attendant at delivery — an accredited health care professional (e.g., a doctor, midwife, or nurse) who can conduct normal deliveries, identify and manage complications, and refer women to the next level of care. To be effective, skilled attendants must have access to drugs and equipment and must be backed by an infrastructure that includes referral systems and good-quality health facilities.
Innovative projects are in progress in a number of countries, involving United Nations agencies, nonprofit organizations, academic institutions, nongovernmental organizations, professional societies, and governments. A major constraint on increasing access to lifesaving services is the severe shortage of skilled health care workers in developing countries, especially in rural areas. However, highly trained specialists are not necessary. Well-trained nurses and midwives can provide basic emergency obstetrical services, such as assisted vaginal delivery and the administration of antibiotics and other drugs. In Mozambique, the Ministry of Health has trained assistant medical officers (nonphysicians) to become surgical technicians and safely perform emergency obstetrical surgery, including cesarean deliveries. These "técnicos de cirurgia" now perform most emergency obstetrical surgery in rural hospitals. A similar approach is being implemented in Tanzania and Malawi. In India, general practice physicians are being trained to perform cesarean deliveries and administer anesthesia, with the support of the Federation of Obstetrics and Gynaecological Societies of India. Maximizing the potential of alternative types of health care workers will require this kind of leadership and cooperation on the part of professional societies.
Another major constraint is the cost of obtaining care. Even where services are officially free, patients in low-resource countries often incur catastrophic costs to obtain the care they need in order to survive. These costs include those of purchasing supplies and drugs in the market because they are unavailable in the facility, securing transport to the facility, and making "informal" payments often required to actually receive care once the patient, supplies, and providers are in place. For ministries of health struggling to strengthen their health care systems and address inequity, resources often fall well short of the minimum levels needed.
Access to emergency obstetrical care is essential to efforts to reduce maternal mortality. Several countries have demonstrated that great strides can be made when maternal health is a political priority. In Sri Lanka and Malaysia, maternal mortality ratios in the early 1950s were more than 500 deaths per 100,000 live births. In subsequent decades, both countries were able to halve these ratios every 6 to 12 years.4 Strategies evolved over time and included professionalizing midwifery, ensuring skilled attendance at childbirth, and developing a system of health care facilities accessible to all women. Thailand, Egypt, and Honduras have also achieved substantial reductions in maternal mortality.5
Unlike the situation 20 years ago, improving maternal health is now high on the global development agenda. One of the eight United Nations Millennium Development Goals embraced by 189 countries in 2000 is to reduce the maternal mortality ratio by 75% by 2015. Most African and some Asian countries are not on track to meet this target, but efforts should continue unabated. Policymakers and health care professionals must continue learning from successful, and unsuccessful, program models and work to scale up effective approaches. To make such expansion possible, donors must substantially increase funding for maternal health programs and research, and the governments of developing countries must establish supportive policies. Although every country has its own history and challenges, accelerating progress is not impossible if political will can be translated into action.
Source Information
Dr. Rosenfield is the dean and a professor of public health and obstetrics and gynecology, Ms. Min a research associate, and Ms. Freedman director of the Averting Maternal Death and Disability Program and a professor of clinical public health at the Mailman School of Public Health, Columbia University, New York.
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