by Yvette Collymore
(November 2003) Arguing that too many pregnant women in developing countries lack access to good medical facilities and care, particularly when emergencies arise, some public health workers are pursuing fresh approaches to ending the death and suffering associated with pregnancy and childbirth in the world's poorest communities.
The latest UN estimates highlight the magnitude of the problem. Roughly half a million women died of risks associated with pregnancy and childbirth in 2000, with some 95 percent of the deaths occurring in Asia (253,000) and sub-Saharan Africa (251,000). Four percent were in Latin America and the Caribbean, and less than 1 percent in more developed countries, according to new estimates by three UN agencies.1
Even though Asia and Africa had an almost equal number of deaths, the risk of maternal death is highest by far in Africa, where countries struggle to provide health services for large, dispersed, mainly rural populations and the average number of children per woman is close to 6.2 Here, a woman has a 1 in 16 chance of dying in pregnancy or childbirth over her lifetime, compared with a 1 in 94 chance in Asia, the UN agencies report. In Europe, where the average number of children per woman is less than 2 and medical care is readily available, a woman has a 1 in 2,400 chance of dying of maternity-related causes.
Most maternal deaths result from excessive bleeding, infections, hypertensive disorders, obstructed labor, or complications from unsafe abortions. Sadly, these emergencies are often difficult to predict.3 In many poor communities, women with complications face delays in deciding to seek care, getting to the appropriate health facility, and receiving treatment once they get there. Efforts to reduce these deaths have included strengthening access to prenatal care, improving women's nutrition, trying to identify high-risk pregnancies early, and training traditional birth attendants.
None of these approaches has had a major impact on maternal mortality. A major challenge is saving lives in poorly functioning health systems. An April 2003 UN background paper on maternal and child health says that strategies including training and deploying skilled attendants and referring complicated cases to emergency facilities rarely try to find out whether the facilities function.4
A four-year-old program based at the Columbia University Mailman School of Public Health and funded by the Bill & Melinda Gates Foundation is trying a new approach. The Averting Maternal Death and Disability (AMDD) Program stresses the importance of improving health systems, particularly emergency obstetric care facilities. AMDD staff note that, even in the best circumstances, women will die if they cannot get to functioning obstetric facilities on time when sudden complications occur.
"Focusing on emergency obstetric care does not negate the importance of other kinds of activities, such as working with the community to encourage families to promptly seek care for women who are ill. Nor does it mean that all pregnant women need to deliver in medical facilities," says Deborah Maine, the AMDD program director. Calling this a "first-things-first" approach, she argues that emergency obstetric services must first function well before the community is mobilized to seek care.5
The AMDD program, which partners with UN agencies, nongovernmental organizations, and government ministries of health in developing countries, conducts more than 50 projects in about 43 countries, assessing the way health facilities and systems function and the quality and use of emergency obstetric care.
Interest in new approaches like AMDD's is being fueled by frustration with persistently high levels of maternal deaths in less developed countries as well as by weaknesses in traditional ways of tracking the problem. Determining maternal mortality ratios — the number of deaths for every 100,000 live births in a population — relies on the gathering of accurate data on the deaths and their causes. These are difficult to come by for a variety of reasons: Many deaths occur outside of health systems and are not recorded; health workers may not always know the causes of death; collecting the data is costly; and calculating the numbers is complex.
The urge for new approaches has increased in light of the need to measure countries' progress toward the Millennium Development Goals set by world leaders in 2000. These include a 75 percent reduction, between 1990 and 2015, in the maternal mortality ratio.
"Now is the time to take up the challenge," says Wendy Graham, the main researcher for the Initiative for Maternal Mortality Programme Assessment (IMMPACT). "Health sector reforms are being implemented in a number of less developed countries. It has long been recognized that maternal health services are dependent on the functioning of the entire health system. … Data are needed to ensure that the most effective and cost-effective intervention strategies for safe motherhood are integrated into essential service packages, and also to track the impact of the reform process using realistic and affordable information systems."6
To achieve these goals, attention has focused on measures released in 1997 by the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and the United Nations Population Fund (UNFPA). Known as "UN process indicators," they provide policymakers and those designing maternal health programs with new kinds of information. While maternal mortality ratios point to levels and frequency of maternal deaths, the UN process indicators monitor the progress of health programs in reducing these deaths. According to the UN agencies, the indicators provide information that can help plan programs, highlight problems, and evaluate programs' success.7
These indicators are already in use to assess health programs in developing countries. For the AMDD program, use of the indicators, following UN guidelines, has provided a range of information on emergency obstetric care facilities, including the following:
While UN agencies do not recommend abandoning traditional measures of maternal mortality, such as the maternal mortality ratio, they note that the process indicators can answer such important questions as why women are dying and how the deaths can be prevented. In the meantime, "Further research is needed to identify cost-effective and reliable ways of measuring maternal mortality," notes Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF, and UNFPA.
Yvette Collymore is senior editor at PRB.
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