23
Towards Ending Preventable Maternal Deaths by 2035 Yves Bergevin, MD, MSc, CCFP, FRCPC, FCFP1
Vincent Fauveau, MD, MPH, PhD2
1 Fonds de Recherche du Québec and Institut National de Santé
Publique du Québec Montréal, Québec, Canada 2 Holistic Santé, Montpellier, France 3 Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
Britt McKinnon, PhD3
Address for correspondence Yves Bergevin, MD, MSc, CCFP, FRCPC, FCFP, Fonds de Recherche du Québec and Institut National de Santé Publique du Québec, 500 Sherbrooke Ouest, bur. 800, Montréal, QC H3A 3C6, Canada (e-mail: [email protected]).
Abstract
Keywords
► maternal mortality elimination ► universal health coverage ► maternal health ► midwifery ► emergency obstetric and newborn care
Maternal mortality has been reduced by half from 1990 to 2010, yet a woman in subSaharan Africa has a lifetime risk of maternal death of 1 in 39 compared with around 1 in 10,000 in industrialized countries. Annual rates of reduction of maternal mortality of over 10% have been achieved in several countries. Highly cost-effective interventions exist and are being scaled up, such as family planning, emergency obstetric and newborn care, quality service delivery, midwifery, maternal death surveillance and response, and girls’ education; however, coverage still remains low. Maternal mortality reduction is now high on the global agenda. We examined scenarios of reduction of maternal mortality by 2035. Ending preventable maternal deaths could be achieved in nearly all countries by 2035 with challenging yet realistic efforts: (1) massive scaling-up and skilling up of human resources for family planning and maternal health; (2) reaching every village in every district and every urban slum toward universal health coverage; (3) enhanced financing; (4) knowledge for action: enhanced monitoring, accountability, evaluation, and R&D.
In 2010, there were an estimated 287,000 maternal deaths in the world; 99% of these maternal deaths were in developing countries and nearly all could have been averted with known highly cost-effective interventions.1,2 And, each year, 1 million babies die within the first 24 hours of life.3 As can be seen in ►Fig. 1, 40 countries had high maternal mortality, defined as having a maternal mortality ratio (MMR) of 300 or more per 100,000 live births. Thirty-five are in sub-Saharan Africa. Haiti is the only high maternal mortality country remaining in the Americas. Two countries had extremely high maternal mortality in 2010, defined as having an MMR of 1,000 or more per 100,000 live births: Chad and Somalia, with MMRs of 1,100 and 1,000, respectively. South Sudan became a new country in 2011 and probably also has extremely high maternal mortality. Ten countries accounted for 60% of all maternal deaths in the world in 2010: India, 56,000; Nigeria, 40,000; Democratic
Issue Theme Global Women’s Health: Challenges and Opportunities; Guest Editor, Eli Y. Adashi, MD, MS, MA (ad eundem), CPE, FACOG
Republic of Congo, 15,000; Pakistan, 12,000; Sudan, 10,000 (in 2010 the figure included South Sudan); Indonesia, 9,600; Tanzania, 8,500; and Bangladesh, 7,200. Around 19,000 maternal deaths were attributed to HIV in 2010, representing 7% of all maternal deaths worldwide. Almost 90% of these were in sub-Saharan Africa, primarily in southern and eastern Africa. Each pregnancy exposes a woman to the risk of a maternal death. Those countries with the highest risk of death at each pregnancy are also the ones with the highest fertility, leading to extremely high lifetime risks of maternal deaths. A woman in Chad has a lifetime risk of a maternal death of 1 in 15; in Somalia, the lifetime risk is 1 in 16. For the whole of subSaharan Africa, the lifetime risk is 1 in 39. A woman in the United States has a lifetime risk of 1 in 2,400, while in Singapore, her risk is 1 in 25,300. The lifetime risk of a maternal death for a woman in Chad is thus over 1,000 times
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1395275. ISSN 1526-8004.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Semin Reprod Med 2015;33:23–29
Toward Ending Preventable Maternal Deaths
Bergevin et al.
Fig. 1 Estimated maternal mortality ratio 2010. (Reprinted with permission from WHO, UNICEF, UNFPA, The World Bank. Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank estimates. Geneva: World Health Organization, 2012.)
that of a woman in Singapore and over 100 times that of a woman in the United States. This human tragedy represents one of the greatest health inequalities in the world. Not only are these deaths tragic in and of themselves, but they also have a profound impact on the future of the family. They can contribute to (1) under-five mortality through newborn deaths and inadequate care of the young children; (2) lower educational attainment, especially for girls who may have to abandon school to look after younger siblings; and (3) lost productivity and income for the household.4 Five direct causes account for the vast majority of maternal deaths: hemorrhage, infection, high blood pressure (preeclampsia, eclampsia), unsafe abortion, and obstructed labor.5 The major determinants of maternal mortality are well known: high fertility; inadequate or delayed access to health services and, in particular, emergency obstetric and newborn care (EmONC) due to financial, geographic, and cultural barriers; low level of girls’ education/gender inequality; poverty; weak communication and transport systems; weak governance/civil strife.6 It is to be noted that for most of the direct causes and for most determinants, cost-effective solutions exist and are being taken to scale.
East Asia achieved an ARR of 5.2%, from a high MMR of 590 to 200, while the Western Pacific achieved the same ARR but from an MMR of 140 to 49. These are impressive figures considering the diversity of countries in each region. They also show that progress can be made at different levels of maternal mortality. Which countries have been best performers? Between 1990 and 2010, Estonia achieved an ARR of 14%, from an MMR of 48 to 2; the Maldives, 12.3% from 830 to 60; Nepal, 7.3% from 770 to 170; and Bangladesh 5.9% from 800 to 240. While progress in sub-Saharan Africa has been generally slower, there are countries that have shown that significant progress can be made: Angola achieved an impressive ARR of 9.5%, from an extremely high maternal mortality of 1,200 to 450; Eritrea 6.3%, from 880 to 240; Ethiopia 4.9%, from 950 to 350; Rwanda 4.9%, from 910 to 340. Each country’s story is unique, yet they all have shown political commitment to scale-up effective interventions, even in the face of extreme poverty for some. The lessons learned together with the observed rates of reduction of maternal mortality from these and many other countries give us a strong basis on how one might make dramatic progress in the coming generation.
Cost-Effective Interventions Unprecedented Progress since 1990 Maternal mortality has been reduced by nearly half in the past 20 years, from 543,000 women in 1990 to 287,000 in 2010.1 Only 40 countries remained in 2010 with high maternal mortality. Progress appears to be accelerating.7 The annual rate of reduction (ARR) in MMR between 1990 and 2010 was 3.1% for the world and 2.7% for Africa. SouthSeminars in Reproductive Medicine
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Highly cost-effective interventions exist (►Table 1).2 However, not all have been taken to scale yet, either because health systems need to be further strengthened or because they have only been operationalized recently and are now being introduced. It is useful to think of these interventions in three broad categories: reproductive health, health system building blocks, and health determinants outside the health system.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
24
Toward Ending Preventable Maternal Deaths
Reproductive Health Related -Family planning -EmONC Health System Related -Service delivery -Health workforce -Medical products -Information Health Determinants Outside of Health Sector -Poverty reduction -Governance -Transport and communication -Girls’ education/women’s empowerment Abbreviation: EmONC, emergency obstetric and newborn care.
Reproductive Health Interventions These have been extensively described elsewhere and will thus be briefly reviewed here.2,8
Family Planning Until recently, family planning (FP) had not received sufficient attention as a potentially life-saving intervention. In a recent article, using robust methods, Ahmed and colleagues demonstrated that meeting the current unmet need for contraception could lead to a 29% reduction in maternal mortality.9 This finding has profound implications for our approach to maternal mortality reduction (MMR). Although there has been recent progress in several countries, contraceptive prevalence rate for modern methods (CPRMM) is still low in sub-Saharan Africa, estimated at 20% in 2012, yet unmet need for family planning remains high at around 31%. In particular, West and Central Africa demonstrate very low contraceptive prevalence in the face of high unmet need; for example, Nigeria had an estimated CPRMM in 2012 of 10% in the face of an unmet need of 27%; Chad had an estimated
25
CPRMM of 4%, yet unmet need stood at 25%.10 Worldwide, more than 220 million women want to plan their families but do not have access to modern family planning information and services.11 Family planning should always be integrated with HIV prevention efforts.12
Emergency Obstetric and Newborn Care Since one cannot predict which women will have complications at delivery, every delivery should be attended by a competent health worker with midwifery skills, capable of providing life-saving basic Emergency Obstetric and Newborn Care (EmONC) and referring to the district hospital for comprehensive EmONC should the woman need a cesarian section or blood transfusion (►Table 2).13 If properly performed in a timely fashion, these can avert the vast majority of maternal deaths.8 In sub-Saharan Africa, the region with the greatest number of maternal deaths, less than 50% of births are attended by a skilled health worker. But some large countries have not yet reached that level, for example, 10% in Ethiopia, 17% in Chad, 18% in Niger, and 34% in Nigeria.14 A global consensus has been forged: to ensure that every pregnancy is wanted and every birth is safe. Yet, most women in sub-Saharan Africa do not have access to family planning and EmONC, life-saving reproductive health interventions.
Health System Strengthening Interventions For countries to deliver universal access to family planning and to EmONC, national health systems will need to be strengthened. The WHO health system framework is a logical way of thinking through the issues that need to be addressed for scaleup toward universal access to reproductive health services (►Fig. 2).15 We focus on four of these building blocks: service delivery, health workforce, medical products, and information.
Service Delivery—FP and EmONC Coverage Family planning information and contraceptives should be made available in every community, in every licensed pharmacy, and in every facility. Round-the-clock maternity services should be offered with sufficient geographic access in every part of every district with at least one basic EmONC
Table 2 Life-saving signal functions of emergency obstetric and newborn care Basic EmONC facility (usually a health center)
Comprehensive EmONC facility (usually a district hospital)
1. Administer parenteral antibiotics
Perform signal functions 1–7, plus:
2. Administer uterotonic drugs
8. Perform surgery (e.g., cesarean section)
3. Administer parenteral anticonvulsants for preeclampsia and eclampsia
9. Perform blood transfusion
4. Manually remove the placenta 5. Remove retained products 6. Perform assisted vaginal delivery 7. Perform basic neonatal resuscitation Abbreviation: EmONC, emergency obstetric and newborn care. Seminars in Reproductive Medicine
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No. 1/2015
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Table 1 Cost-effective interventions
Bergevin et al.
Toward Ending Preventable Maternal Deaths
Bergevin et al.
Fig. 2 The WHO health system framework. (Reprinted with permission from World Health Organization. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva: 2007.)
health center per 100,000 population and one comprehensive EmONC district hospital per 500,000 population.13 The United Nations Population Fund (UNFPA), UNICEF, and Columbia University are together supporting high maternal mortality countries in carrying out national EmONC surveys to map out current levels of EmONC service delivery. To date, 34 have been performed or have been planned and financed.7 These form the basis for national district-by-district micro-planning of scale-up for sustained impact; they are used for advocacy and resource mobilization, both domestically and with donors; and provide a baseline against which future progress can be measured.
Health Workforce—Midwifery Competencies The shortage of health workers trained in providing EmONC is perhaps the greatest challenge in reducing maternal mortality. The first ever State of the World’s Midwifery Report published in 2011 provided a detailed picture of the situation.16 UNFPA has been supporting—through its Maternal Health Thematic Fund —national efforts to strengthen midwifery education and training in over 30 countries.7 Although the results are promising, much more is needed to be done to accelerate the training of midwives and enhance further the quality of their education, especially hands-on clinical training.
Medical Products—Life-Saving Commodities The recent work by the UN Commission on Life-Saving Commodities has highlighted the low or extremely low availability and use of commodities such as oxytocin, misoprostol, or magnesium sulfate.17 For example, in preparatory work for this Commission and using results of the 2008 national EmONC survey in Ethiopia, which covered over 750 facilities, we calculated effective population coverage of oxytocin, misoprostol, and magnesium sulfate at 6% or less.18
Information—Maternal Death Surveillance and Response The estimates of maternal mortality presented earlier in this article have been extremely useful and have contributed to galvanize action. However, by the very nature of the methSeminars in Reproductive Medicine
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odology required, they lack sufficient precision, are only available every 5 years or so, and cannot provide data at the subnational level, which is required for action. All maternal deaths should be reported as recommended by the Commission on Information and Accountability for Women’s and Children’s Health.19 Maternal death reviews and audits should then follow to understand why these maternal deaths occurred. Corrective actions can then be taken to avert any such future deaths, leading to continuous quality improvement of maternity services. Recently, a global guidance on Maternal Death Surveillance and Response has been produced and countries are now beginning to introduce systematically this quality assurance process.20,21 The publication of MDSR data can be a strong catalyst for action within the ministry of health, districts, and can muster political commitment and action.
Health Determinants beyond the Health System Poverty Poverty has been reduced since 1990 and most high maternal mortality countries are showing signs of sustained economic growth. Not only are households being lifted out of poverty, but also governments have increasing resources to pay for health service delivery to which is added valuable development assistance for health.
Governance Governance has improved considerably in the past two decades and the number of high maternal mortality countries facing civil strife has been reduced to a handful. However, as South Sudan, the Central African Republic, Somalia, and the eastern part of the Democratic Republic of the Congo have shown us recently, several high maternal mortality countries are still quite fragile. Although some progress in reducing maternal deaths is possible even in humanitarian settings, a certain level of governance and of stability is required to strengthen health systems for sustained impact and to achieve major reductions of maternal deaths.
Transport and Communication Reducing the delays to seek care has been critical to lower maternal mortality. Transport and communications have made important strides in the past two decades. In particular, the use of mobile phones for emergency health services in developing countries has contributed to both improved access and response times—for example, in Bangladesh. Their use in Maternal Death Surveillance and Response is being piloted.7
Girls’ Education and Gender Equality Gender inequality is a profound determinant of maternal mortality; one the most effective interventions toward gender equality and women’s empowerment is the education of girls. The education of a woman is in itself an extremely powerful determinant of health and of development.22,23 While there has been considerable progress in improving
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26
access to, and completion of primary school in least developed countries, only a third of secondary school-aged children are in school, with 81 girls for every 100 boys.24–26 Only a quarter of secondary school-aged girls remain in school and many fewer will complete secondary school.
Maternal Mortality Reduction High on the Global Agenda The Millennium Development Goals (MDGs) placed maternal mortality high up on the global agenda with the ambitious target of MDG5—To Improve Maternal Health—to reduce the MMR by three quarters from 1990 to 2015. Since 2008, there has been a systematic effort by the United Nations to accelerate progress, including joint work by the WHO, UNFPA, UNICEF, and The World Bank, which were recently joined by UNAIDS and UN Women, the group now known as H4 þ .27 UN Secretary General Ban Ki-Moon launched the Global Strategy on Women’s and Children’s Health Every Woman Every Child encouraging national governments to make public commitments toward maternal and child health and to hold each other accountable.28 As part of this global effort, UNFPA launched its Maternal Health Thematic Fund to provide enhanced technical and financial support to high maternal mortality countries.6,7 Maternal health is now firmly on the global agenda. Recalling that 220 million women who wanted to plan their families did not have access to family planning information and services, the London Family Planning Summit (FP2020) set to reach an additional 120 million women to have access to modern contraceptives by 2020. FP 2020 was hosted by the UK Department for International Development and the Bill & Melinda Gates Foundation with UNFPA and other partners.29
Can We End Preventable Maternal Deaths by 2035? The full impact of a strategy to end preventable maternal deaths by 2035 will be felt once cost-effective interventions are delivered with high quality and universal coverage (>95%) is achieved. In the case of family planning, this translates in every woman, every couple having access to the required information and services to make and realize an informed choice. The target date of 2035, twenty years after the target date of 2015 for the MDGs, is increasingly chosen as an appropriate time point for global health targets.30,31 As mentioned earlier in the article, two regions, SouthEast Asia and the Western Pacific achieved annual rates of reduction of MMR of 5.2% from 1990 to 2010; Bangladesh achieved an ARR of 5.9% and Nepal of 7.3%; all of these reductions were achieved with coverage levels in the middle range for the main interventions: family planning, EmONC, the required health systems’ building blocks, or girls’ education. A few countries had ARRs above 12%, demonstrating that such high rates of decline are achievable at national level with currently available interventions.
Bergevin et al.
We have thus examined three scenarios of ARRs between 2010 and 2035 to see what the situation might be in 2035: scenario 1, an ARR of 5.2% based the estimated mean ARR over the past two decades for the regions of South-East Asia and the Western Pacific; scenario 2, an ARR of 7.3% applying the rate achieved by Nepal; and scenario 3, an ARR of 10%, estimated on the basis of what we believe should be achievable given universal coverage (>95%) of the above interventions and what has been already achieved by some countries. At which cut-off should we consider that a country has eliminated preventable maternal mortality as a public health problem? Low maternal mortality is considered as less than 100 per 100,000 live births.1 In this article, we have arbitrarily chosen a cut-off of less than 50 per 100,000 live births by 2035, a figure where one can consider that maternal mortality is no longer a significant public health problem. In 2010, 75 countries had already reached such a cut-off.1 ►Table 3 presents the number of countries not having reached this target under the three scenarios. Countries that have achieved ARR of 10% or more had very high coverage of the aforementioned interventions. Under scenario 3, with an ARR of 10%—a challenging but feasible scenario—only nine countries would not have reached the MMR target of
Towards Ending Preventable Maternal Deaths by 2035 Yves Bergevin, MD, MSc, CCFP, FRCPC, FCFP1
Vincent Fauveau, MD, MPH, PhD2
1 Fonds de Recherche du Québec and Institut National de Santé
Publique du Québec Montréal, Québec, Canada 2 Holistic Santé, Montpellier, France 3 Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
Britt McKinnon, PhD3
Address for correspondence Yves Bergevin, MD, MSc, CCFP, FRCPC, FCFP, Fonds de Recherche du Québec and Institut National de Santé Publique du Québec, 500 Sherbrooke Ouest, bur. 800, Montréal, QC H3A 3C6, Canada (e-mail: [email protected]).
Abstract
Keywords
► maternal mortality elimination ► universal health coverage ► maternal health ► midwifery ► emergency obstetric and newborn care
Maternal mortality has been reduced by half from 1990 to 2010, yet a woman in subSaharan Africa has a lifetime risk of maternal death of 1 in 39 compared with around 1 in 10,000 in industrialized countries. Annual rates of reduction of maternal mortality of over 10% have been achieved in several countries. Highly cost-effective interventions exist and are being scaled up, such as family planning, emergency obstetric and newborn care, quality service delivery, midwifery, maternal death surveillance and response, and girls’ education; however, coverage still remains low. Maternal mortality reduction is now high on the global agenda. We examined scenarios of reduction of maternal mortality by 2035. Ending preventable maternal deaths could be achieved in nearly all countries by 2035 with challenging yet realistic efforts: (1) massive scaling-up and skilling up of human resources for family planning and maternal health; (2) reaching every village in every district and every urban slum toward universal health coverage; (3) enhanced financing; (4) knowledge for action: enhanced monitoring, accountability, evaluation, and R&D.
In 2010, there were an estimated 287,000 maternal deaths in the world; 99% of these maternal deaths were in developing countries and nearly all could have been averted with known highly cost-effective interventions.1,2 And, each year, 1 million babies die within the first 24 hours of life.3 As can be seen in ►Fig. 1, 40 countries had high maternal mortality, defined as having a maternal mortality ratio (MMR) of 300 or more per 100,000 live births. Thirty-five are in sub-Saharan Africa. Haiti is the only high maternal mortality country remaining in the Americas. Two countries had extremely high maternal mortality in 2010, defined as having an MMR of 1,000 or more per 100,000 live births: Chad and Somalia, with MMRs of 1,100 and 1,000, respectively. South Sudan became a new country in 2011 and probably also has extremely high maternal mortality. Ten countries accounted for 60% of all maternal deaths in the world in 2010: India, 56,000; Nigeria, 40,000; Democratic
Issue Theme Global Women’s Health: Challenges and Opportunities; Guest Editor, Eli Y. Adashi, MD, MS, MA (ad eundem), CPE, FACOG
Republic of Congo, 15,000; Pakistan, 12,000; Sudan, 10,000 (in 2010 the figure included South Sudan); Indonesia, 9,600; Tanzania, 8,500; and Bangladesh, 7,200. Around 19,000 maternal deaths were attributed to HIV in 2010, representing 7% of all maternal deaths worldwide. Almost 90% of these were in sub-Saharan Africa, primarily in southern and eastern Africa. Each pregnancy exposes a woman to the risk of a maternal death. Those countries with the highest risk of death at each pregnancy are also the ones with the highest fertility, leading to extremely high lifetime risks of maternal deaths. A woman in Chad has a lifetime risk of a maternal death of 1 in 15; in Somalia, the lifetime risk is 1 in 16. For the whole of subSaharan Africa, the lifetime risk is 1 in 39. A woman in the United States has a lifetime risk of 1 in 2,400, while in Singapore, her risk is 1 in 25,300. The lifetime risk of a maternal death for a woman in Chad is thus over 1,000 times
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1395275. ISSN 1526-8004.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Semin Reprod Med 2015;33:23–29
Toward Ending Preventable Maternal Deaths
Bergevin et al.
Fig. 1 Estimated maternal mortality ratio 2010. (Reprinted with permission from WHO, UNICEF, UNFPA, The World Bank. Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank estimates. Geneva: World Health Organization, 2012.)
that of a woman in Singapore and over 100 times that of a woman in the United States. This human tragedy represents one of the greatest health inequalities in the world. Not only are these deaths tragic in and of themselves, but they also have a profound impact on the future of the family. They can contribute to (1) under-five mortality through newborn deaths and inadequate care of the young children; (2) lower educational attainment, especially for girls who may have to abandon school to look after younger siblings; and (3) lost productivity and income for the household.4 Five direct causes account for the vast majority of maternal deaths: hemorrhage, infection, high blood pressure (preeclampsia, eclampsia), unsafe abortion, and obstructed labor.5 The major determinants of maternal mortality are well known: high fertility; inadequate or delayed access to health services and, in particular, emergency obstetric and newborn care (EmONC) due to financial, geographic, and cultural barriers; low level of girls’ education/gender inequality; poverty; weak communication and transport systems; weak governance/civil strife.6 It is to be noted that for most of the direct causes and for most determinants, cost-effective solutions exist and are being taken to scale.
East Asia achieved an ARR of 5.2%, from a high MMR of 590 to 200, while the Western Pacific achieved the same ARR but from an MMR of 140 to 49. These are impressive figures considering the diversity of countries in each region. They also show that progress can be made at different levels of maternal mortality. Which countries have been best performers? Between 1990 and 2010, Estonia achieved an ARR of 14%, from an MMR of 48 to 2; the Maldives, 12.3% from 830 to 60; Nepal, 7.3% from 770 to 170; and Bangladesh 5.9% from 800 to 240. While progress in sub-Saharan Africa has been generally slower, there are countries that have shown that significant progress can be made: Angola achieved an impressive ARR of 9.5%, from an extremely high maternal mortality of 1,200 to 450; Eritrea 6.3%, from 880 to 240; Ethiopia 4.9%, from 950 to 350; Rwanda 4.9%, from 910 to 340. Each country’s story is unique, yet they all have shown political commitment to scale-up effective interventions, even in the face of extreme poverty for some. The lessons learned together with the observed rates of reduction of maternal mortality from these and many other countries give us a strong basis on how one might make dramatic progress in the coming generation.
Cost-Effective Interventions Unprecedented Progress since 1990 Maternal mortality has been reduced by nearly half in the past 20 years, from 543,000 women in 1990 to 287,000 in 2010.1 Only 40 countries remained in 2010 with high maternal mortality. Progress appears to be accelerating.7 The annual rate of reduction (ARR) in MMR between 1990 and 2010 was 3.1% for the world and 2.7% for Africa. SouthSeminars in Reproductive Medicine
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Highly cost-effective interventions exist (►Table 1).2 However, not all have been taken to scale yet, either because health systems need to be further strengthened or because they have only been operationalized recently and are now being introduced. It is useful to think of these interventions in three broad categories: reproductive health, health system building blocks, and health determinants outside the health system.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
24
Toward Ending Preventable Maternal Deaths
Reproductive Health Related -Family planning -EmONC Health System Related -Service delivery -Health workforce -Medical products -Information Health Determinants Outside of Health Sector -Poverty reduction -Governance -Transport and communication -Girls’ education/women’s empowerment Abbreviation: EmONC, emergency obstetric and newborn care.
Reproductive Health Interventions These have been extensively described elsewhere and will thus be briefly reviewed here.2,8
Family Planning Until recently, family planning (FP) had not received sufficient attention as a potentially life-saving intervention. In a recent article, using robust methods, Ahmed and colleagues demonstrated that meeting the current unmet need for contraception could lead to a 29% reduction in maternal mortality.9 This finding has profound implications for our approach to maternal mortality reduction (MMR). Although there has been recent progress in several countries, contraceptive prevalence rate for modern methods (CPRMM) is still low in sub-Saharan Africa, estimated at 20% in 2012, yet unmet need for family planning remains high at around 31%. In particular, West and Central Africa demonstrate very low contraceptive prevalence in the face of high unmet need; for example, Nigeria had an estimated CPRMM in 2012 of 10% in the face of an unmet need of 27%; Chad had an estimated
25
CPRMM of 4%, yet unmet need stood at 25%.10 Worldwide, more than 220 million women want to plan their families but do not have access to modern family planning information and services.11 Family planning should always be integrated with HIV prevention efforts.12
Emergency Obstetric and Newborn Care Since one cannot predict which women will have complications at delivery, every delivery should be attended by a competent health worker with midwifery skills, capable of providing life-saving basic Emergency Obstetric and Newborn Care (EmONC) and referring to the district hospital for comprehensive EmONC should the woman need a cesarian section or blood transfusion (►Table 2).13 If properly performed in a timely fashion, these can avert the vast majority of maternal deaths.8 In sub-Saharan Africa, the region with the greatest number of maternal deaths, less than 50% of births are attended by a skilled health worker. But some large countries have not yet reached that level, for example, 10% in Ethiopia, 17% in Chad, 18% in Niger, and 34% in Nigeria.14 A global consensus has been forged: to ensure that every pregnancy is wanted and every birth is safe. Yet, most women in sub-Saharan Africa do not have access to family planning and EmONC, life-saving reproductive health interventions.
Health System Strengthening Interventions For countries to deliver universal access to family planning and to EmONC, national health systems will need to be strengthened. The WHO health system framework is a logical way of thinking through the issues that need to be addressed for scaleup toward universal access to reproductive health services (►Fig. 2).15 We focus on four of these building blocks: service delivery, health workforce, medical products, and information.
Service Delivery—FP and EmONC Coverage Family planning information and contraceptives should be made available in every community, in every licensed pharmacy, and in every facility. Round-the-clock maternity services should be offered with sufficient geographic access in every part of every district with at least one basic EmONC
Table 2 Life-saving signal functions of emergency obstetric and newborn care Basic EmONC facility (usually a health center)
Comprehensive EmONC facility (usually a district hospital)
1. Administer parenteral antibiotics
Perform signal functions 1–7, plus:
2. Administer uterotonic drugs
8. Perform surgery (e.g., cesarean section)
3. Administer parenteral anticonvulsants for preeclampsia and eclampsia
9. Perform blood transfusion
4. Manually remove the placenta 5. Remove retained products 6. Perform assisted vaginal delivery 7. Perform basic neonatal resuscitation Abbreviation: EmONC, emergency obstetric and newborn care. Seminars in Reproductive Medicine
Vol. 33
No. 1/2015
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Table 1 Cost-effective interventions
Bergevin et al.
Toward Ending Preventable Maternal Deaths
Bergevin et al.
Fig. 2 The WHO health system framework. (Reprinted with permission from World Health Organization. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva: 2007.)
health center per 100,000 population and one comprehensive EmONC district hospital per 500,000 population.13 The United Nations Population Fund (UNFPA), UNICEF, and Columbia University are together supporting high maternal mortality countries in carrying out national EmONC surveys to map out current levels of EmONC service delivery. To date, 34 have been performed or have been planned and financed.7 These form the basis for national district-by-district micro-planning of scale-up for sustained impact; they are used for advocacy and resource mobilization, both domestically and with donors; and provide a baseline against which future progress can be measured.
Health Workforce—Midwifery Competencies The shortage of health workers trained in providing EmONC is perhaps the greatest challenge in reducing maternal mortality. The first ever State of the World’s Midwifery Report published in 2011 provided a detailed picture of the situation.16 UNFPA has been supporting—through its Maternal Health Thematic Fund —national efforts to strengthen midwifery education and training in over 30 countries.7 Although the results are promising, much more is needed to be done to accelerate the training of midwives and enhance further the quality of their education, especially hands-on clinical training.
Medical Products—Life-Saving Commodities The recent work by the UN Commission on Life-Saving Commodities has highlighted the low or extremely low availability and use of commodities such as oxytocin, misoprostol, or magnesium sulfate.17 For example, in preparatory work for this Commission and using results of the 2008 national EmONC survey in Ethiopia, which covered over 750 facilities, we calculated effective population coverage of oxytocin, misoprostol, and magnesium sulfate at 6% or less.18
Information—Maternal Death Surveillance and Response The estimates of maternal mortality presented earlier in this article have been extremely useful and have contributed to galvanize action. However, by the very nature of the methSeminars in Reproductive Medicine
Vol. 33
No. 1/2015
odology required, they lack sufficient precision, are only available every 5 years or so, and cannot provide data at the subnational level, which is required for action. All maternal deaths should be reported as recommended by the Commission on Information and Accountability for Women’s and Children’s Health.19 Maternal death reviews and audits should then follow to understand why these maternal deaths occurred. Corrective actions can then be taken to avert any such future deaths, leading to continuous quality improvement of maternity services. Recently, a global guidance on Maternal Death Surveillance and Response has been produced and countries are now beginning to introduce systematically this quality assurance process.20,21 The publication of MDSR data can be a strong catalyst for action within the ministry of health, districts, and can muster political commitment and action.
Health Determinants beyond the Health System Poverty Poverty has been reduced since 1990 and most high maternal mortality countries are showing signs of sustained economic growth. Not only are households being lifted out of poverty, but also governments have increasing resources to pay for health service delivery to which is added valuable development assistance for health.
Governance Governance has improved considerably in the past two decades and the number of high maternal mortality countries facing civil strife has been reduced to a handful. However, as South Sudan, the Central African Republic, Somalia, and the eastern part of the Democratic Republic of the Congo have shown us recently, several high maternal mortality countries are still quite fragile. Although some progress in reducing maternal deaths is possible even in humanitarian settings, a certain level of governance and of stability is required to strengthen health systems for sustained impact and to achieve major reductions of maternal deaths.
Transport and Communication Reducing the delays to seek care has been critical to lower maternal mortality. Transport and communications have made important strides in the past two decades. In particular, the use of mobile phones for emergency health services in developing countries has contributed to both improved access and response times—for example, in Bangladesh. Their use in Maternal Death Surveillance and Response is being piloted.7
Girls’ Education and Gender Equality Gender inequality is a profound determinant of maternal mortality; one the most effective interventions toward gender equality and women’s empowerment is the education of girls. The education of a woman is in itself an extremely powerful determinant of health and of development.22,23 While there has been considerable progress in improving
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access to, and completion of primary school in least developed countries, only a third of secondary school-aged children are in school, with 81 girls for every 100 boys.24–26 Only a quarter of secondary school-aged girls remain in school and many fewer will complete secondary school.
Maternal Mortality Reduction High on the Global Agenda The Millennium Development Goals (MDGs) placed maternal mortality high up on the global agenda with the ambitious target of MDG5—To Improve Maternal Health—to reduce the MMR by three quarters from 1990 to 2015. Since 2008, there has been a systematic effort by the United Nations to accelerate progress, including joint work by the WHO, UNFPA, UNICEF, and The World Bank, which were recently joined by UNAIDS and UN Women, the group now known as H4 þ .27 UN Secretary General Ban Ki-Moon launched the Global Strategy on Women’s and Children’s Health Every Woman Every Child encouraging national governments to make public commitments toward maternal and child health and to hold each other accountable.28 As part of this global effort, UNFPA launched its Maternal Health Thematic Fund to provide enhanced technical and financial support to high maternal mortality countries.6,7 Maternal health is now firmly on the global agenda. Recalling that 220 million women who wanted to plan their families did not have access to family planning information and services, the London Family Planning Summit (FP2020) set to reach an additional 120 million women to have access to modern contraceptives by 2020. FP 2020 was hosted by the UK Department for International Development and the Bill & Melinda Gates Foundation with UNFPA and other partners.29
Can We End Preventable Maternal Deaths by 2035? The full impact of a strategy to end preventable maternal deaths by 2035 will be felt once cost-effective interventions are delivered with high quality and universal coverage (>95%) is achieved. In the case of family planning, this translates in every woman, every couple having access to the required information and services to make and realize an informed choice. The target date of 2035, twenty years after the target date of 2015 for the MDGs, is increasingly chosen as an appropriate time point for global health targets.30,31 As mentioned earlier in the article, two regions, SouthEast Asia and the Western Pacific achieved annual rates of reduction of MMR of 5.2% from 1990 to 2010; Bangladesh achieved an ARR of 5.9% and Nepal of 7.3%; all of these reductions were achieved with coverage levels in the middle range for the main interventions: family planning, EmONC, the required health systems’ building blocks, or girls’ education. A few countries had ARRs above 12%, demonstrating that such high rates of decline are achievable at national level with currently available interventions.
Bergevin et al.
We have thus examined three scenarios of ARRs between 2010 and 2035 to see what the situation might be in 2035: scenario 1, an ARR of 5.2% based the estimated mean ARR over the past two decades for the regions of South-East Asia and the Western Pacific; scenario 2, an ARR of 7.3% applying the rate achieved by Nepal; and scenario 3, an ARR of 10%, estimated on the basis of what we believe should be achievable given universal coverage (>95%) of the above interventions and what has been already achieved by some countries. At which cut-off should we consider that a country has eliminated preventable maternal mortality as a public health problem? Low maternal mortality is considered as less than 100 per 100,000 live births.1 In this article, we have arbitrarily chosen a cut-off of less than 50 per 100,000 live births by 2035, a figure where one can consider that maternal mortality is no longer a significant public health problem. In 2010, 75 countries had already reached such a cut-off.1 ►Table 3 presents the number of countries not having reached this target under the three scenarios. Countries that have achieved ARR of 10% or more had very high coverage of the aforementioned interventions. Under scenario 3, with an ARR of 10%—a challenging but feasible scenario—only nine countries would not have reached the MMR target of
