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Maternal Mortality: We Already Know What Works…Or Do We?
September 9, 2010
This is a joint post with April Harding.
In a recent pitch for the $63 billion Global Health Initiative (see my post on the event), U.S. Secretary of State Hillary Clinton responded to a question about measuring progress in women’s health. “We are focusing on maternal mortality because that is so measurable. We know where we have a better idea of what works and what it will take to have more women deliver babies successfully. There’s all kinds of interventions from the very simplest, like a safe birthing kit, which is a piece of twine and a clean razor blade and a bar of soap and a piece of plastic to put under the women, all the way up to tertiary care for complicated pregnancies…”
Is this true? What do we (the global health community) know? What more do we have to learn?
Secretary Clinton is right, almost. We know that certain patient interventions can save women’s lives. For example, attendant-supervised deliveries and emergency interventions to address obstetric complications like hemorrhage, obstructed delivery etc. reduce delivery-related deaths.
What we don’t know, unfortunately, is which programs or service delivery strategies will get these interventions to the women who need them, especially in weak health systems where most avoidable maternal deaths take place.
What Has Worked? Why?
Maternal mortality rates are falling in some countries, as documented in a recent study by Hogan et al. 2010. The analysis shows that over an 18 year period (1990-2008), countries including Egypt, Romania, Bangladesh, India and China had substantial success in reducing maternal mortality. However, only a few case studies have documented program strategies, let alone evaluated the outcomes. Evidence from Sri Lanka shows that long-term government commitment to broad, systematic improvements of health services for pregnant women can have a dramatic affect on maternal mortality rates, but we don’t know how to apply these insights to other health systems contexts.
As I wrote in an earlier blog post:
We are just beginning to learn more about the effects of contraceptive use on the number of maternal deaths (fertility decline has a lot to do with reducing a woman’s risk of dying during pregnancy because it reduces the frequency of her “exposure” to pregnancy). We also know that while proven technologies needed to prevent most of the [350,000-500,000] maternal deaths that occur every year already exist (a fact which has prompted the WHO to designate such deaths as “avoidable”) we have almost NO evidence (see here for a succinct summary of the empirical evidence or lack thereof of interventions including traditional birth attendant training, increased skilled attendance at birth, antenatal care, community mobilization, and dissemination of clean delivery kits) from developing countries to support the claim that any single intervention can effectively reduce maternal mortality.
We don’t know which program strategies will work in developing countries to achieve sizable increases in access to and use of these services or “service delivery interventions.” This lack of knowledge has undermined most health programs (as April Harding discusses in the forthcoming 2011 CGD book “Private Patients: Why Health Aid Fails to Reach So Many, and What We Can Do About It”). For instance, unsuccessful service delivery strategies may be to blame for the failure of the Integrated Management of Childhood Illness approach, the standard program used to reduce child mortality for the past 15 years. (Victora et al 2006) Maternal health programs have had similar difficulties finding service delivery strategies which improve coverage of the patient interventions which will save women. (Hill et al 2007)
What doesn’t work is equally important. At the recent Global Health Maternal Conference in New Delhi, Wendy Graham made a plea to the global health community to not only learn from successes but also from failures. We have limited resources—both donor and domestic—and to use these well, we need to learn how to make the best investments. Policies—donor and government—that drive the allocation of these limited resources need to keep up with technical know-how AND with the challenges of delivering these technologies in different contexts.
The Long Road from Effective Patient Interventions to Saving Lives
Within the global health policy stratosphere, focus is often on mobilizing resources and making commitments to solve global health challenges in the developing world. While this focus is understandable and commendable, we must also talk about how to connect that money and policy productively to implementation. Unless we recognize the big problems in devising successful strategies to deliver services in a specific developing country context, we will certainly not solve these pressing global health challenges.
The big push (money and policy) on maternal and child health at the global policy level is very welcome. But connecting these global resources to implementation for impact (read: fewer and fewer women and children die due to pregnancy and childbirth related causes) is critical. How will these new initiatives do better than previous ones in reaching the people they are trying to help? Interventions, no matter how effective, will not help people they cannot reach. The imminent MDG Summit 2010 is an opportunity for world leaders to commit to saving more women’s lives, especially when we know we can do it.
Possibly Related Posts
- Making Sense of New Maternal Mortality Numbers: Four Take-Aways for Policy and Research Action
- Canada Reported Ready to Spend $1 Billion to Cut Maternal Mortality—How To Use the Money Well
- Women Deliver 2010: A Second Chance for the World to Deliver for Women
3 Responses to “Maternal Mortality: We Already Know What Works…Or Do We?”
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September 10th, 2010 at 9:15 am
In response to your point:
We don’t know which program strategies will work in developing countries to achieve sizable increases in access to and use of these services or “service delivery interventions.”
One strategy that is proving very effective in achieving large increases in service utilisation is providing services free at the point of delivery. For example in Burundi only 22% of babies were born in health units in 2005 but following the removal of fees in 2006 this proportion rose to 56% in 2008. See also http://www.povertyactionlab.or.....h-products
September 17th, 2010 at 3:04 am
Hi Nandini,
I am very glad to see the CGD topic on Maternal Mortality: We Already know what works…Or Do We? This means I am going to learn a lot from CGD as their fan, who founded a midwives association for her country; to counteract the maternal and child mortality. I will always keep in touch.
Sincerely
Francisca ‘Mapitso Matsoha.
September 20th, 2010 at 4:48 pm
Dear Nandini,
I tried posting this earlier but it seemed not to take. But if it did, sorry to be repetitive.
I’m not certain we know what works–maybe more importantly, that we want to recognize what has worked.
In April, The Lancet published a research article by the University of Washington, funded by the Gates Foundation. It documented the fact that maternal mortality had declined from 538,300 annually in 1980 to 347,900 in 2008. The editor reported that various WHO-affiliated groups had called him, requesting that publication be delayed. Their numbers were so much higher than those of The Lancet and they were concerned that lower numbers would unduly influence donors. The editor refused and published.
In October 2008, UNICEF reported that infant deaths had declined from 20 million annually in 1960 to 9.7 million in 2006. It credited this fall to immunizations and economic development. WHO was sorely vexed with this publication.
The failure to recognize progress in maternal and infant mortality masks the oncoming emergence of chronic diseases in these same countries.
This month, The New England Journal of Medicine had an article in which the authors said that \non-communicable diseases are among the most severe threats to global economic development. It is projected that in the next ten years, China and India will lost $558 billion, and $237 billion, respectively, in national income as a result of only four chronic diseases.
In 2004, the Columbia University’s school of public health issued a study called: A Race Against Time. It found that: \in Brazil, the number of CVD deaths in women aged 15-34 is twice that from pregnancy-related causes. In addition, the number of Brazilian CVD deaths in the decade after prime child bearing years, 35-44 years, is nearly five time the deaths from pregnancy-related causes during the two decades of ages 15-44. This pattern applies in China where there are 61% more CVD deaths in women aged 15-34 than deaths from maternal conditions. In subsequent decades,three times as many women will die from CVDs as died from maternal conditions in the previous decade.\
In research conducted by Hudson Institute on the emergence of chronic diseases in emerging market economies, two key finding were:
1. the age-specific onset of chronic diseases is 10-15 years younger than in the West;
2. and, the indirect costs (lost productivity, increased absenteeism in the work force, etc.( were far greater than the direct costs (facility treatment or prevention), subordinating health concerns to an economic context.
A World Bank book in 1999 (see The Health of Adults in the Developing World) stated that \the adult population is the productive sector of society. Any impairment of its capacity through disease or disability will inevitably lead to a decline in national productivity and a slowdown in overall national development. Ths in turn will adversely affect the health of persons of all ages within the population.\
At present, adult-ill health is an unfunded liability in a gathering storm, one that will eventually push a tsunami of costly chronic diseases onto the shores of fragile economies.
To the extent that we fail to recognize this emergence, recipient governments will diminish their political and fiscal support for parasitic and infectious diseases. They see it as our priority but increasingly not theirs.
Two other findings in the Gates funded study of April point to this potential:
1. while development health aid jumped from $8 billion in 1995 to $19 billion in 2006, health aid to government had a negative effect on domestic spending, such that for every $1 of health aid, government health expenditures from domestic sources were reduced by 0.43 cents;
2. on debt forgiveness, it had no detectable effect on governments’ domestic health spending. (They were supposed to have increased their domestic health and education budgets by an amount equal to that which was forgiven)
Best,
Jeremiah Norris