3. Delays Recognized in Maternal Mortality

Lubna Hassan¹ and Lauren Woodbury²

(1)

Women’s Health Intervention and Development Initiative (WHI-DI), The Woman’s Hospital, and SAFOG MNH Committee, Peshawar, Pakistan

(2)

WHI-DI, Peshawar, Pakistan

Lubna Hassan (Corresponding author)

Lauren Woodbury

3.1 Introduction

If you want to judge a country, see how it treats women—Abdul Ghaffar Khan.

A version of this quote has been attributed to many sources; regardless of the source, it is very relevant because it strikes at the heart of the issue of maternal mortality. The status of women in a given country is inextricably linked to their health, and the reason women die giving birth is no mystery. We know why over 800 women, primarily from the developing world, die every day. They die because they have no or limited access to quality health care. The majority of maternal deaths occur due to direct obstetric causes—hemorrhage, preeclampsia, eclampsia, obstructed labor, sepsis, and unsafe/incomplete abortions or miscarriages. Importantly, deaths from these complications are preventable as treatments are well known and relatively inexpensive [1]. If all women had access to appropriate care, it is estimated that 80–74% of maternal deaths could be averted [2].

This is a crucial moment in the global effort to reduce maternal mortality since it is a time of transition from the Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs). Whether countries can implement lessons learned from the MDGs will determine if they succeed in saving women’s lives. Achieving the goals laid out in SDG 3.1 and the WHO’s elimination of preventable maternal mortality (EPMM) initiative will require national level commitments and the combined efforts of all stakeholders including governments, the relevant UN agencies, national and international NGOs, and the OB/GYN community [3]. The OB/GYN community in South Asia, led by the South Asian Federation of Obstetrics and Gynecology (SAFOG), has tremendous power to be in the vanguard by directly addressing shortfalls in the strategies to eliminate preventable maternal deaths and by helping to overcome the “three delays” in accessing care. The first delay: delay in seeking care results from the low status of women, lack of awareness of complications and risk factors, and/or financial limitations. The second delay: delay in reaching care is usually due to issues around accessibility including distance from a health facility, prohibitive cost of health care, lack of transportation, and poor infrastructure. The third delay: delay in receiving care results from quality of care issues including poor facilities or lack of supplies/equipment, poorly trained personnel, or an inadequate referral system for complicated cases [4].

In the short term, medical causes must be addressed, primarily through emphasizing quality throughout the continuum of care. In the longer term, the contributing social, cultural, and economic factors must also be addressed. Importantly, one must understand that a high rate of maternal death is not an isolated phenomenon. It extends from a lifetime of marginalization experienced by women and girls including poor health and malnutrition in childhood, which continues through adolescence and pregnancy resulting in anemia and other complications. Frequent and inadequately spaced pregnancies and socioeconomic factors like poverty, illiteracy, and lack of empowerment all contribute to high maternal mortality rates.

3.2 Background: The Global Response

The story of the neglected tragedy of maternal mortality is well documented. After the publication of the now famous article “Where is the M in MCH?” [5] and the introduction of the Safe Motherhood Initiative in 1987, maternal mortality reduction has gradually gained worldwide attention. A global consensus on what must be done and an increased commitment in many countries rose from this enhanced awareness. In 1999 a joint statement from the WHO, UNFPA, UNICEF, and the World Bank called on countries to “ensure that all women and newborns have skilled care during pregnancy, childbirth and the immediate postnatal period” [6].

In 2000, the UN adopted the UN Millennium Declaration. This historic agreement included eight critical goals—the MDGs—for combating poverty and accelerating human development to be achieved by 2015. MDG 5 (Improve Maternal Health) had two targets:

(a)

All countries reduce maternal mortality by 75% from the 1990 maternal mortality ratio.
(b)

Achieve universal access to reproductive health.¹

Thanks to efforts toward MDG 5 globally, a 44% reduction in the maternal mortality rate (MMR) occurred from 385 per 100,000 live births in 1990 to an estimated 216 in 2015. The annual number of maternal deaths decreased by 43% from 532,000 in 1990 to an estimated 303,000 in 2015. The approximate global lifetime risk of maternal death fell from 1 in 73 to 1 in 180. These figures indicate a substantial reduction, but it is far short of the goal of 75% [7, 8]. Between 1990 and 2015, estimated MMR declined across all MDG regions. However, there is considerable variation in the amount of the reduction between regions and income groups. The estimated lifetime risk of maternal mortality in low-income countries is 1 in 41 which is vastly worse than high-income countries (1 in 3300). Today developing regions accounted for approximately 99% of the global maternal deaths. The worst performing regions are sub-Saharan Africa which alone accounts for roughly 66% of deaths followed by South Asia [9, 10].

3.2.1 The Sustainable Development Goals

Building on the experience gained from efforts to achieve MDG 5, the SDGs establish an enhanced and more comprehensive agenda for maternal health. The aim of SDG 3.1 is to reduce the global MMR to less than 70 per 100,000 live births by 2030 and to have no country with an MMR above 140. This is significantly below the current global MMR of 216. Achieving the SDG target will require reducing global MMR by an average of 7.5% every year. This is more than three times the annual rate of reduction (2.3%) from 1990 to 2015 [10].

The SDGs provides a more holistic framework that emphasizes the need for universal health coverage [11] and a focus on equity. MNCH has been expanded to Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH). The UN Secretary-General released the Global Strategy for Women’s, Children’s and Adolescents’ Health 2016–2030 at the same time as the adoption of the SDG declaration. It provides a broad multi-stakeholder framework for the implementation, follow-up, and review of progress toward the goals. The UN Secretary-General’s strategy is complimented by the WHO’s elimination of preventable maternal mortality initiative [3].

3.2.2 Emphasizing Quality of Care

Importantly, new global efforts have refocused from simply increasing coverage to highlighting the importance of quality of care. This came about due to the realization that merely increasing the quantity of interventions has not been enough to reduce maternal mortality to target levels. A likely explanation for this discrepancy is the poor quality of care in many health facilities [12]. To address this issue, a core set of indicators for improving and reporting on quality of care in facilities providing maternal, newborn, and child health services has been developed by the WHO and the Partnership for Maternal, Newborn and Child Health [13]. The emphasis is on the following areas:

1.

Routine care during childbirth, including monitoring of labor and newborn care at birth and during the first week.
2.

Management of preeclampsia, eclampsia, and its complications.
3.

Management of difficult labor with safe, appropriate medical techniques.
4.

Management of postpartum hemorrhage.
5.

Newborn resuscitation.
6.

Management of preterm labor and birth and appropriate care for preterm and small babies.
7.

Management of maternal and newborn infections [14].

3.2.3 Importance of Data

Measuring maternal mortality remains an immense challenge, and new global efforts highlight the importance of accurate data. Measuring progress requires robust, internationally comparable civil registration systems. However, the very countries that have a high MMR also have poor data collection systems. Globally 60% of countries do not have accurate data on maternal deaths [15]. Instead, they rely on estimates, and under-reporting continues to be a major issue. Those countries that have reduced their maternal mortality now need to focus on comprehensive maternal death registration to ensure no cases are missed. Importantly, data must also be disaggregated below the national level. If it is not, the average decrease at country level masks pockets of high mortality within countries. Among those countries with low overall maternal mortality, the next challenge is measuring and rectifying inequities among their populations.

Importantly while accurate data is useful for tracking progress toward national goals, alone it does not provide information on the causes of and circumstances that lead or contribute to maternal deaths. This type of detailed information must also be collected as it is crucial for designing effective interventions. Detailed information can only be obtained through maternal death reviews (MDR) or audits [16] which ideally would be conducted as part of a complete, national Maternal Death Surveillance and Response (MDSR) system. MDSR is a system that measures and investigates maternal deaths in real time to help stakeholders including the government, donor agencies, NGOs, and health-care workers at all levels understand the underlying factors contributing to the deaths. The primary goal is to eliminate preventable maternal mortality by obtaining and strategically using information to guide public health actions and monitor their impact. Emphasizing response is what makes MDSR more effective than other approaches which gather information but don’t necessarily lead to action [17].

Performance of MDR (a key component of MDSR) is one of the WHO’s core indicators on a country’s progress in reducing maternal mortality. Use of these indicators in monitoring quality of care along with the implementation of the MDSR approach will contribute to greater accountability for maternal health and more efficacious coverage of lifesaving interventions, thereby contributing to the end of preventable maternal mortality [17].

3.3 South Asia Current Trends and Remaining Challenges

South Asia is home to 1.6 billion people across eight countries: Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka. The reduction in the MMR in the region has been substantial from 550 in 1990 to 190 in 2013. This is a reduction of 65%, the highest rate globally. However, even with this reduction, South Asia still has the second highest rate of maternal deaths, accounting for roughly 24% of global maternal deaths [9]. The table above displays the trends in maternal mortality of South Asian countries from 1990 to 2015 (Fig. 3.1)².

../images/421078_1_En_3_Chapter/421078_1_En_3_Fig1_HTML.png — Fig. 3.1

Trends in MMR among SAR countries, 1990–2015

There are similarities as well as disparities between and within the South Asian countries. At one end of the spectrum is Sri Lanka, which has health statistics that is nearly comparable to developed countries. The graph shows Sri Lanka’s extremely low level of MMR compared to the rest of the region. However, Sri Lanka did not technically achieve MDG 5 because it was unable to reduce its maternal mortality by 75%. This paradox illustrates a gap in the MDGs which dealt in averages and wanted a fixed decrease regardless of the starting point. This shortcoming has been resolved in the SDGs [18]. Like most South Asian countries, Sri Lanka has limited resources and has had its share of disturbances including a civil war. Nonetheless, it still managed to develop its social sector. Successful implementation of MDR and a commitment to universal access are credited with Sri Lanka’s low MMR [16]. This is a lesson for other countries in terms of what can be achieved if priorities are set correctly.

Bhutan and the Maldives have also done exceptionally well and were the two countries in the region that achieved MDG 5 with declines of 84 and 90%, respectively. Afghanistan and Nepal also made significant progress falling just short of MDG 5 with declines of 70 and 71%. Nevertheless, Afghanistan’s progress notwithstanding it still remains one of the world’s “high-MMR” countries at over 400 per 100,000 live births. The three most populace countries, Bangladesh, India, and Pakistan, all made progress but failed to achieve MDG 5 [10]. However, given that their populations combine to account for roughly half of all South Asia, the progress they did make contributed the most to the overall region-wide decline in the total number of maternal deaths: India (74.1%), Bangladesh (12%), and Pakistan (7.6%).Within India, three states, Uttar Pradesh/Uttaranchal, Bihar/Jharkhand, and Rajasthan, contributed more than 50% of the total of India’s decline in maternal deaths, while other states lagged behind [9]. Notably, Pakistan started out in 1990 with the second lowest MMR in the region after Sri Lanka, but given its very slow rate of progress, it now has a higher MMR than most countries in the region. In 2015 Pakistan’s estimated MMR stood at 178 which is higher than Bangladesh (176), India (174), Bhutan (148), Maldives (68), and Sri Lanka (30) [10].

The gender inequality that persists in every domain of South Asian societies underpins the factors hindering further reductions in MMR. These include high fertility rates, high rates of early marriage and pregnancy, lack of access to family planning, inequity in access to maternal health services, and malnutrition (a frequent underlying cause of maternal deaths) [19].

Moreover, with a few notable exceptions, national and provincial/state governments have failed to follow through on stated commitments. Conspicuously absent in most cases is the necessary budget allocations. The result is short-term or ad hoc interventions rather than comprehensive health system improvements. In addition to an overall funding gap for maternal health at the national level, there are large disparities in the targeting of donor funding and country needs. Some very poor countries with high MMRs have gotten comparatively little funding, while some wealthier countries have gotten more funds [20]. Similarly, progress is undermined by inadequate oversight and coordination of projects leading to wasted resources, duplication of effort, and corruption. Lack of laws or insufficient enforcement of laws to protect women and girls including a failure to prevent child marriage have also hindered efforts to reduce maternal mortality.

Finally, as mentioned earlier, a lack of complete data hampers the ability to design effective interventions and to track progress. With the exception of Sri Lanka, South Asian countries rely on estimates derived from limited surveys and extrapolations of piecemeal facility-based data. In most countries representative community-based data on maternal deaths is almost totally lacking. The WHO estimates that the MMR is underestimated by 30% globally and by up to 70% in some countries [21]. The figure below displays the range in in maternal mortality estimates for South Asian countries (Fig. 3.2)³.

../images/421078_1_En_3_Chapter/421078_1_En_3_Fig2_HTML.png

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Recognized in Maternal Mortality

3. Delays Recognized in Maternal Mortality

3.1 Introduction