Dr M Islam, Director, Making Pregnancy Safer, WHO. 20, avenue Appia, 1211 Geneva 27 Switzerland Email: firstname.lastname@example.org
Only 6 years are left until 2015, the target date for achieving the Millennium Development Goals (MDG), yet improving maternal health (MDG 5) continues to lag behind. At the global level, maternal mortality still remains high in sub-Saharan Africa and Southeast Asian countries. Most deaths are preventable and occur due to unavailability of and/or poor quality of service.
Skilled care at facilities ensures safety, cleanliness, the availability of supplies and equipment, and it makes management and supervision easier. With the mixture of professionals in a facility, life-saving emergency care can be provided quickly. Wherever childbirth takes place, it is essential that the person who helps has the core competencies for safe delivery, has the necessary equipment and supplies, and has the option to refer to a functioning facility offering emergency obstetric and newborn care.
The continuing high incidence of maternal and perinatal mortality and morbidity is unacceptable precisely because it is solvable. We know how to make pregnancy and childbirth safe. The task is enormous but not insurmountable. Our efforts of investment need to be equal to the tasks and must be intensified if maternal and perinatal morbidity and mortality is to be reduced.
Only 6 years are left until 2015, the target date for achieving the Millennium Development Goals (MDG), yet improving maternal health (MDG 5) continues to lag behind. Progress has been patchy and results uneven. A large number of countries have made progress in providing skilled care during childbirth improving the health and well-being of mothers and their newborns. However, countries with the highest burdens of mortality and ill-health have made least progress. Inequalities between countries are increasing. Within one single country there can be striking inequities and differences between population groups and national figures mask substantial internal variations—geographical, economical, and social. Rural populations have less access to skilled care than urban populations, within urban settings mortality is higher among urban slum populations, rates can vary widely by ethnicity or by wealth status, and remote areas bear a particularly heavy burden of deaths. Priority for scaling up skilled care should be given to these population groups who are currently marginalised.
What is MDG 5?
MDG 5 aims to improve maternal health. This goal was translated into two targets:
• to reduce maternal mortality by three-quarters between 1990 and 2015, and
• to achieve universal access to reproductive health by 2015.
The two key indicators for monitoring the progress towards the first target are the maternal mortality ratio and the proportion of births attended by skilled health personnel.
What progress has been made on MDG 5?
According to the 2005 data, few low- and middle-income countries are on track to achieve the first target of MDG 5. In 56 of the 68 priority countries where 98% of maternal deaths occur, mortality ratios are still high, exceeding 300 maternal deaths per 100 000 live births.1 The global maternal mortality ratio is 400 maternal deaths per 100 000 live births versus 430 in 1990. At the global level, maternal mortality still remains high in sub-Saharan Africa and Southeast Asian countries (Figure 1).
The analysis of trends shows that maternal mortality has decreased at an average of <1% annually between 1990 and 2005 – far below the 5.5% annual decline, which is necessary to achieve the Maternal mortality ratio (MMR), concerning maternal mortality reduction. To achieve that goal, MMRs will need to decrease at a much faster rate in the future – especially in sub-Saharan Africa, where the annual decline has so far been approximately 0.1%. Achieving this goal requires increased attention to improved health care for women, including high-quality emergency obstetric care2 (Figure 2).
Nevertheless, there is a sense of progress, illustrated by the increase in uptake of care during pregnancy and childbirth. The proportion of births in low- and middle-income countries assisted by a skilled birth attendant increased from 47% in 1990 to 61% in 2006 (Figure 3). However, coverage is far lower than the global targets set at a special session of the United Nations General Assembly in 1999 to follow-up the 1994 International Conference on Population and Development: 80% by 2005, 85% by 2010 and 90% by 2015. The regions with the lowest proportions of skilled health attendants at birth were eastern Africa (34%), western Africa (41%) and south-central Asia (47%), which also had the highest numbers of maternal deaths.3
The second target of MDG 5 constitutes the main goal of the International Conference on Population and Development: ‘Achieve, by 2015, universal access to reproductive health’. This was incorporated within the MDG monitoring framework under MDG 5 based on the recommendations of world leaders at the 2005 World Summit.4 Universal access to reproductive health refers to the ability to achieve sexual and reproductive health (including maternal health) through health care, as defined within the Programme of Action of the International Conference on Population and Development (the constellation of methods, techniques and services that contribute to health and well-being by preventing and solving reproductive health problems).5 It implies ‘equitable access’, in which individuals with equal need have equal access to relevant health care.
The use of contraception has improved impressively during the past two decades in many regions. However, the unmet need for family planning is still unacceptably high in low- and middle-income countries. In sub-Saharan Africa, 24% of women who want to delay or stop childbearing have no access to family planning. This figure varies between 10 and 15% in the other world regions and further varies across population groups. For example, in Latin America and the Caribbean, an average of 27% of the poorest households have an unmet need for family planning versus 12% of the wealthiest group.
Antenatal care is a crucial service for healthy motherhood and childbirth by monitoring the well-being of both the woman and her baby. The proportion of pregnant women in low- and middle-income countries who had at least one antenatal care visit increased from <55% in the early 1990s to almost 75% in a decade. Although this is an improvement, the recommended norm of four antenatal visits is still not accessible to many pregnant women worldwide: for example, 55% of those in sub-Saharan Africa.
Pregnancy in adolescence contributes to the cycle of maternal deaths and indicates limited access to reproductive health services. Adolescent fertility declined in almost all low- and middle-income countries between 1990 and 2000, but either remained stagnant or increased marginally between 2000 and 2005.
Way forward for reducing maternal mortality
A very large proportion of maternal and perinatal deaths are avoidable. Most deaths occur due to unavailability of and/or poor quality of service provision, as well as lack of access to and use of these services. During political instability or in conflict zones, the situation can deteriorate even further. Interventions that can prevent mortality from the major causes of maternal death are known, and can be made available even in resource-poor settings. These include focusing on adequate care and preparation in the household, assuring quality services close to where women live and systematically detecting and managing complications at an early stage.
Although effective interventions to prevent mortality are known, for many women and newborns, appropriate care remains unavailable, unused, inaccessible, or of poor quality. The ability for women to access quality family planning services, postabortion care services and, where legally permissible, safe abortion services is also associated with reduced maternal and perinatal deaths.
For optimum safety, every woman without exception needs skilled care during pregnancy, childbirth and in the immediate postpartum period, given in an appropriate environment (usually in decentralised, first-level facilities) close to her home, in a way that respects her culture. This can avert, contain or solve many of the life-threatening problems particularly the complications that may arise during childbirth, and it can reduce maternal and newborn mortalities and stillbirth to surprisingly low levels.
Some women are more vulnerable to having complications in childbirth. They include adolescents below 19 years, women above 40 years, women with more than 4–5 children and with short birth spacing intervals (below 18 months), and women with previous caesarean section. Targeting these women for skilled care, as priority, may further accelerate the reduction of maternal and newborn mortalities.
There is a close correlation between skilled birth attendance and institutional deliveries. Experience – from countries as diverse as Botswana, China, Cuba, Honduras, Malaysia, the Netherlands, South Africa, Sri Lanka, Sweden, Thailand and the UK (Figure 4) – provide ample information on the benefits of facility-based deliveries and their significant impact in reducing maternal and newborn mortality. In countries that have increased their coverage of skilled birth attendants, facility-based delivery was the option chosen by women and by policy-makers. The advantages of facility-based deliveries – both from a technical perspective and from systematic analysis of mothers’ experiences – are many. They enable teamwork, so that midwives can attend far more births than would be possible in home deliveries and make higher coverage with skilled attendance possible. They also enable non-professionals, such as assistants and auxiliaries, to help making care more cost-effective. This allows a single midwife to attend up to 175–220 deliveries per year with faster improvement of coverage, compared to about 50 deliveries or less per year for a single-handed midwife visiting mothers at home with lower coverage.6
In addition, the mixture of professionals in a facility means that life-saving emergency care can be given quickly. Skilled care at facilities also ensures safety, cleanliness, the availability of supplies and equipment, and it makes management and supervision easier. Other health care can be performed, and referrals are easier, as is emergency transport. In addition, quality facility childbirth care provides the best opportunity to organise and provide timely emergency obstetric and newborn care. Wherever childbirth takes place, it is essential that the person who helps has the core competencies for safe delivery, has the necessary equipment and supplies, and has the option to refer to a functioning facility offering emergency obstetric and newborn care.
There is a great concern that at current trends, the international community will fail to meet its MDG of reducing by three-quarters the maternal mortality ratio in 2015. If these targets are to be met, then the international community will need to redouble its efforts. What has been missing until now is a concrete global plan – and focused efforts at the country level – to translate these international commitments into lives saved. The continuing high incidence of maternal and perinatal mortality and morbidity is unacceptable precisely because it is solvable – we know how to make pregnancy and childbirth safe. The task is enormous but not insurmountable. Our efforts of investment need to be equal to the tasks and must be intensified if maternal and perinatal morbidity and mortality is to be reduced.