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.
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
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.