A Comprehensive Approach Required
With only five years remaining until the Millennium Development Goals (MDGs) target date of 2015, Dr Alison Morgan from the Nossal Institute for Global Health writes about the increasing attention being paid to MDG5.
MDG 5 aims to provide access to reproductive health services for all women, and reduce the number of maternal deaths by 75 per cent. (1)
Of all the MDGs, MDG5 is making the least progress.
Maternal mortality is a significant marker of inequity in health; half a million women die each year as a result of complications of pregnancy and childbirth, and 99 per cent of these deaths occur in developing countries (2)So what makes reducing maternal deaths so difficult? And why, when many have been working to improve the health of women, is this goal so hard to attain? Improving maternal health is complex as it is the product of a range of determinants including the status of women, their access to family planning and antenatal services, support at the community level for safer deliveries, and the effectiveness of the health system.
These determinants have guided responses to the problem of poor maternal health and there is consensus that a continuum of care approach is required.
Young women need to have access to education and good nutrition.
They need to be able to choose whether and when they become pregnant, and they need to receive quality antenatal, delivery and postnatal care, with access to emergency obstetric services should they need it. As most deaths occur at the time of delivery, there has been a significant focus on the provision of quality obstetric services by scaling up the number of trained health workers, thereby increasing the number of woman delivering with a skilled birth attendant. Currently some 60 million women deliver every year without skilled assistance.
In 2005, the World Health Organisation (WHO) estimated there was a global shortfall of over 133,000 midwives. (3)
While it is true that most deliveries occur without complications, most emergencies
cannot be predicted. Consequently every woman needs to be able to access emergency care at the time of delivery, if she should require it. And for those who do deliver at home, if and when an emergency does occur, every step in the path to receiving care has to be working if we are to prevent a maternal death.
cannot be predicted. Consequently every woman needs to be able to access emergency care at the time of delivery, if she should require it. And for those who do deliver at home, if and when an emergency does occur, every step in the path to receiving care has to be working if we are to prevent a maternal death.
At the time of the complication, a mother and her family need to be able to recognise the need for care and to get to a health facility quickly. The facility needs to be prepared to manage the complication, which may require anaesthesia, a caesarian and possibly a blood transfusion. All of these components need to be working well, and, as there is the chance of the emergency happening at night, such care needs to be available 24 hours a day. Delays can occur at any of these steps in the pathway to quality care - recognising the need for care, being able to reach the care, and then receiving the appropriate care at the health facility.
Delaying care for women with complicated deliveries also contributes to significant disability for women, as for every maternal death, another 20 women are left with injuries that may result in ongoing pain, infertility or, in the case of obstetric fistula, devastating social exclusion.
However, it is not sufficient to focus on the health system alone, and there are many strategies to support those deliveries that still occur at home. The important role of mothers, their families, and traditional birth attendants in contributing to better maternal health, overlooked for many years, is being increasingly recognised. Simple interventions, such as highlighting the needs of mothers and newborns in monthly mothers' group meetings, have been shown to reduce newborn deaths. (4)
Implementing clean delivery practices, and providing community access to drugs such as misoprostol, which reduces the amount of bleeding after a delivery, can reduce deaths from sepsis and haemorrhage.
The important role played by cultural beliefs and practices associated with delivery has been substantially overlooked and even ignored in the past, but this is also beginning to change.
So where has progress been made and what role can volunteers contribute towards the achievement of MDG5?
Nepal provides some interesting lessons. This country has recently emerged from 10 years of civil conflict where there was disruption of already stretched health services, yet Nepal's maternal mortality ratio (MMR) almost halved from 539 per 100,000 live births in 2001 to 281 in 2006. (5)
In the same period, the number of women who had a skilled birth attendant did not change from a very low 18 percent. In that time, however, women's literacy levels and other indicators of empowerment improved. Family planning services were more accessible and the total fertility rate dropped. Abortion services were legalised and made available in all 75 districts.
There were many initiatives supported by INGOs and government agencies to mobilise communities to recognise the importance of care during pregnancy and delivery. The consequent reduction in MMR highlights what is possible where emergency obstetric services might be lagging.
Nepal has also introduced a range of innovative strategies to improve access to and the quality of care provided by the health system. Women who travel to a health facility for their delivery are now given money to cover transport costs, and since 2009, all delivery care in government hospitals has been free. Currently, a program to train an additional 12,000 midwives to provide the required skilled birth attendance is underway. In fact, Nepal is one of a very few countries that may reach their MDG5 target with this comprehensive approach.
Volunteers can make an important contribution to the achievement of MDG5.
They can train skilled health workers, work with communities to raise awareness of the care required during pregnancy and delivery, as well as promote the rights of women. Maternal mortality is a marker of both gender inequity and health system weakness, and improvements are only possible where governments, donors and development partners work to ensure that all women have access to comprehensive reproductive health care throughout their lives.
Footnotes
1 Compared to 1990 rates
2 UNICEF http://www.unicef.org/health/index_maternalhealth.html
3 WHO 2005 World Health Report: Make Every Woman and Child Count
4 Manandhar D, Osrin D, Shrestha B, et al. 2004 Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 364: 970-79
5 Nepal Demographic and Health Surveys 2001 and 2006
2 UNICEF http://www.unicef.org/health/index_maternalhealth.html
3 WHO 2005 World Health Report: Make Every Woman and Child Count
4 Manandhar D, Osrin D, Shrestha B, et al. 2004 Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 364: 970-79
5 Nepal Demographic and Health Surveys 2001 and 2006
About Dr Alison Morgan
Dr Alison Morgan has over 20 years' experience in international health in the fields of maternal health, primary health care and child and adolescent health.
She has developed curricula in maternal health for health workers in Tibet and Indonesia, and teaches postgraduate students in the Masters of Public Health at the University of Melbourne and Monash University.
She has supervised research on maternal health needs in two states of India, and for three years was the safe motherhood adviser on an AusAID bilateral project in Tibet.
She has worked in curriculum design and health workforce capacity building across eight counties of Asia, and heads the Education and Learning Unit of the Nossal Institute for Global Health at the University of Melbourne.
She is on the steering committee for the Gates/AusAID-funded multicountry investment case to reach MDGs 4 and 5 for the Asia Pacific, and a member of the technical advisory panel for the AusAID-funded Women's and Children's Knowledge Hub.
