(April 2007) In most developing countries, women still face a significant risk of dying or having a serious or life-threatening complication during pregnancy, delivery, or after. These risks can be dramatically reduced through already known cost-effective interventions. But political will and resources continue to lag.

During a PRB Discuss Online, Dr. Fariyal Fikree, technical director of health communications at PRB, answered participants’ questions about the barriers to implementation and successful strategies for ensuring that women survive pregnancy and childbirth.

April 18, 2007 12:45 PM EST

Transcript of Questions and Answers

Thank you for taking part in this PRB online discussion. The number of questions submitted exceeded our ability to answer them in the allotted time. If there is a question you would like Dr. Fikree to answer, please e-mail her at: ffikree@prb.org.

Rahat Bari Tooheen
: I still believe that women empowerment holds the answer to this question. Even though many initiatives have been taken over the years, women empowerment considers the social factors which may facilitate or hamper initiatives to reduce death rates from pregnancy and childbirth. What changes, in your opinion, should be undertaken in current and future efforts to ensure that women empowerment plays a bigger role in the stated problem?
Fariyal Fikree, M.D.: Women’s empowerment does play a role but, from my perspective, not a major role in reducing maternal deaths. Decision to seek care, a significant women’s empowerment indicator, will facilitate seeing care earlier though I think that physical accessibility, health systems issues (availability of trained personnel, equipment and supplies – see my answer to Barbara Tokun’s question) and affordability are the major contributors to maternal mortality.

Dr. P. Hanson
: In some developing countries the private sector has stepped in to assist in the reduction of martenal mortality , by providing marternity services. However, these also have limitations and martenal mortality cases are still happenning due to causes such as (lack of refferal services, delayed identification of high risk groups, lack of safe blood for transfusion. In casesa susch as these the question is “How should the respective countrie’s policies be refined and strengthened to enable the private sector to assist in providing quality care and to assist in reducing the disease burden than to create another strain on the overburden system?” I am asking this question form a country where the health sector is currently undergoing a reform to support one national plan, ultimately through a pooled fund system.
Fariyal Fikree, M.D.: The role of the private sector in national health programs is increasingly being recognized. This is an excellent development though, as you remarked, there are barriers and challenges. I think that the private sector can facilitate the provision of good quality health care, specifically maternal and newborn care, by good quality competency-based training programs (including in-service); role models for clinic-based audits for maternal and newborn mortality and near-miss cases. Your country is embarking on a pooled fund system operational plan and perhaps is assessing the potential roles that the private sector can play. The above examples will provide a niche for further discussions.

Robert Zinser
: Which training do you recommend for midwives, CHEWs and TBAs in Nigeria to increase the number of attended births? Which basic documents/checklists should they have? Is there a proven training schedule available?
Fariyal Fikree, M.D.: In Nigeria as in several developing countries, most births and especially those in rural areas are conducted by traditional birth attendants with minimal or no formal training. WHO and Unicef have training programs for TBAs that have been implemented for several years. I recommend that you approach the country offices of WHO/Unicef/UNFPA to obtain their training curricula. The American College of Nurse Midwives Life Saving Skills training and Midwifery programs are other sources. The International Confederation of Midwives

(http://www.internationalmidwives.org) and WHO’s Making Pregnancy Safer (http://www.who.int/making_pregnancy_safer/en/) are other good resources to consider.

Dr Palanivel
: why mmrcontinues to be high in developing world?
Fariyal Fikree, M.D.: This is a good question and not a simple one to answer. I would say that there are several reasons that include health systems (for normal and complicated/emergency care, skilled personnel, equipment and supplies), accessibility (geographic and social including women’s empowerment (addressed in my response to Rahat Toheen) and affordability. Countries, such as Sri Lanka and Malaysia, that have reduced maternal mortality have done so by improving the quality of maternity services (at the community and facility levels), providing emergency obstetric care while at the same time tackling the broader social issues. Reducing maternal mortality is not only a development issue but also equity and human rights issues – the advocacy surrounding these paradigms (development, equity and human rights) in the context of Safe Motherhood has not been as focused and passionate as it should be.

Barbara S. Okun
: Could you please outline the cost-effective policies that could be instituted to reduce maternal mortality in developing societies? And what are the barriers to their institution?
Fariyal Fikree, M.D.: Skilled birth attendance (community or facility levels) coupled with emergency obstetric care are, from my perspective, the cost-effective policy and programmatic policy recommendations that policy makers and policy advocates need to push for with one voice. The major barriers to implementation include but are not limited to skilled personnel (midwives mainly), efficient referral system (including personnel trained to conduct c-sections), equipment and supplies (especially blood banks). A significant barrier is health manpower and health system infrastructure that can reach the most in need.

Nyakina, J.D. ( M.D.)
: 1.underallocation Vs misallocation ?of resources govts for reproductive health care services delivery(for both community and hospital-level coverage) 2. more expanded packege of motivation/incetives to individuals(doctors,nurses,other related paramedics,etc) and facilities(dispensaries,health centres, hospitals.), NOT neccessarily cash only,could that add more to both quality and quantity RCHS delivery? 3.can’t Decentralization be more efficient than the centralized approach(current practice by most of the Govts in the developing countries,international and local NGOs giving funds to govts)in planning and prioritarization,budgeting,funding and allocation of the resources,and supervision of activities and resource utilization in reaching the remote communities?
Fariyal Fikree, M.D.: The question you pose is a familiar one that is being grappled at various levels (internationally and nationally). A primary concern, from my perspective, is the evidence based approach to identifying the main health policy focus (burden of disease, equity and human rights) and, at the programmatic level, the cost-effective interventions to implement. In this context, harmonization (through SWAPS and other similar mechanisms) among donors and Ministry of Health, Planning and Finance for an equitable allocation of resources is the logical next step.

There have been several attempts to provide a different package of incentives (career development, attending national and international conferences, education for children etc). Some of these have proved successful in improving the quality of care and has improved the health manpower deployment in under-served areas. Are these approaches replicable at the national level in large countries such as India and Nigeria is debatable though warrants serious consideration from my perspective. The debate between central and decentralized approaches is contentious and fraught with good and poor experiences. However, the move more recently for public-private partnerships and its implementation in several countries is a significant improvement but the long-term impact needs to be assessed.

Y.S. Sivan
: A considerable proportion of deaths from pregnancy and child births in the poorer regions of the world could be attributed to social determinants. Accessibility – the gap between innovation and end-user – play an important role. Madam, in your opinion, are the governments, United Nations agencies and non-governmental organizations giving due weightage to the social determinants of health (SDH) angle of deaths from pregnancy and child births? Would having an exclusive SDH component (and a sub-component with medical anthropological approach) in each of the programmes aimed at improving maternal health help reduce the problem considerably? Thank you.
Fariyal Fikree, M.D.: The role that the social determinants of health play in reducing deaths from pregnancy has been raised earlier (see my response to question by Rahat Tooheen). Mahmoud Fathalla’s work “Why did Mrs X die” has been highlighted by WHO in the late eighties and continues as a component in the pathway to reducing maternal deaths.

Linda Suttenfield
: Are you able to provide statistics on the effect that pregnancy-related maternal mortality has on the death of children under 5? In other words, if the mother dies during childbirth, then what is the increased risk to her living children?
Fariyal Fikree, M.D.: You ask a good question but unfortunately one that has not been extensively researched. To the best of my knowledge, the death of a mother profoundly affects family stability – mortality among infants born alive to mothers who died from maternal causes was nearly 95% in Bangladesh, 37% (Pakistan) and 22% in Egypt. However, evidence for the increased mortality and morbidity risk for children under five is scanty. Your question hence raises the issue that the donor community and policy makers need to address to document the long term consequences of saving women’s lives.

Barbara B. Crane
: Could you address the potential for new technologies such as misoprostol to save women’s lives and what are the barriers to making them more available?
Fariyal Fikree, M.D.: The potential for misoprostol in postpartum hemorrhage is excellent as evidenced by the current spate of research. There are still several ongoing field trails that make me even more optimistic regarding the future potential of such new technologies. However, as with any new technology there are barriers and challenges. These include programmatic implementation concerns from the context of providers (doctors in facilities versus TBAs, active management of third stage of labor versus no active management – WHO’s recommendation for the prevention of PPH) and upscaling (Cost-effectiveness of misoprostol to control postpartum hemorrhage in low-resource settings S.E.K. Bradley, N. Prata, N. Young-Lin and D.M. Bishai] in IJGO).

Soma Dey
: Do you think that pregnancy at later ages increases the possibility of maternal death or still birth?
Fariyal Fikree, M.D.: Age (less than 18 and over 35) are risk factors for maternal mortality.

Enayat ur Rehman
: Dr Fikree, How can we reduce this risk in Pakistan with lack of access to trained skill birth attendants along with numerous socio-cultural barriers.
Fariyal Fikree, M.D.: There is no simple answer to your question. It is one of developing a strategic approach, based on cost-effective interventions, that is long term and sustainable.

Diana Zulu
: How can we reduce death rates in a country like Zambia where only 43 percent of woment deliver at the hands of skilled birth attendants and this is mostly in the rural areas. What about that rural women who have no access a health facility and later on does not even know about antenatal clinic?
Fariyal Fikree, M.D.: A good question and one that reflects an issue that several of us who have worked in developing countries continue to debate. The need to advocate for greater attention to save women’s lives (as a development, human rights and equity issue) is one of paramount importance especially in 2007 – the 2oth anniversary of the Safe Motherhood strategy with few gains. Equitable distribution of resources for saving women’s lives encompasses the MDGs and poverty reduction strategies and a mantra that, from my perspective, needs to be strongly advocated at the national, regional and global levels.

: If the context is developing countries, what can we say are the causes? If women in the western countries do not suffer similar feats, what is the difference between the two worlds?
Fariyal Fikree, M.D.: A vast difference … see my response to the earlier question. Saving women’s lives in developing coutnries is an issue of development, equity and human rights – issues that have long been neglected among the developing country policy advocates and oen that is not a major issue in the developed world.

Dr. Ebony Quinto
: I believe the health and other social service delivery systems in developing are largely dysfunctional and are far from being overhauled and being alined to provide a baisc survival package to mothers and their babies according to their needs. How can we get these systems and their technical and political managers to delivery in the shortest term?
Fariyal Fikree, M.D.: the shortest term approach is getting the polciy makers and donors to come to an agreement on the cost-effective interventions that will provide teh greatest gain. Advocacy and harmonization among the donor community (multilateral and bilateral) governemnt ministries (health, plannign and finance) and NGOs with regards to their programmatic focus will achieve significant resutls in the short terms (see the Honduras example)

Mary G
: If you could talk to the women of the the Philippines, what would you advise them on reducing death rates from pregnancy and childbirth?
Fariyal Fikree, M.D.: Not a straightforward answer. from my perspecitve a multi-pronged approach that included policy advocacy, programmatic strategies based on cost-effective interventions and donor harmonization all play a significant role. How the women of the Philippines go about workign towards this end is a process but your question begins that process.

: In order to reduce death rates ,you must understand that every locality has its perculiarity in terms of religious believes, culture,health indicators and that, it is a woman’s problem as far as Africa is concerned.So there is need to educate the girl child on her physiology and other associated risks and death during her life time at all stages of their education, so that when options are given to her ,she is empowered to choose the right to live and not die thru pregnancy/chilbirth.Here in Nigeria, most females are not enligthened enough to know the risks,associatedproblems and possible solutions, so they are often exposed to risks thru religious instructions and beliefs not to believe in hospitals, ceaserian sections for surgical intervention, drugs, antenatal attendance, and other help they may require to save their lives in case of a problem associated with birth, at times cultural settings play a major role in this negetive beliefs , aggressive empowerment of a girl child at all stages of their lives will nullify all negative believes and this will go a long way to help and let all woman be concious that they do not have to die during births, thank you.
Fariyal Fikree, M.D.: You have raised several important and significant aspects in the long road to saving womens’ lives … and an aspect that I have, in my work, long strived to achieve. this is the life cycle approach and one that encompasses development, human rights and equity. The social determinants of health is, from one perspective, a development issue though also includes human rights and equity.

Dr. Yamini Sarwal
: One of the major hurdles is inequitable allocation of resources, so that the most needy are the most deprived. What programs and policies can help in making the essential and emergency obstetric care available to the deprived sections?
Fariyal Fikree, M.D.: Your question is “a real life” dilemma … and one that I have been stressing in this online discussion session. It is the issue of development and equity and in that context the inequitable allocation of resoruces. Unfortunately, there is no ‘gold standard’ approach to address this issue. My outlook is the need for a harmonization among the donor community, relevant government ministies and NGOs (including private-public partnerships)to critically assess the areas where most input is needed adn to address these strategically.


The MMR in India continues to be very high,despite the fact that there are proven interventions avalialble, Recently Government of India, annnounced the following strategies: The current strategy for reducing maternal deaths hinges on three simultaneous efforts, namely: ASHA – Janani Suraksha Yojna – Skilled Birth Attendant: A village level health worker (ASHA- Accredited Social Health Activist), will identify pregnant women, and motivate them to avail services. The Janani Suraksha Yojna will provide financial support to poor women, above the age of 19 years, for their first two deliveries, and a third only if she undergoes sterilization at the time of delivery. The skilled birth attendant will be a person with the ability to not only delivery babies, but to handle life-threatening risks immediately. Universal institutional delivery: Birth should occur only in government health centres and hospitals, or in private nursing homes where the doctors will be provided with a fixed fee for normal delivery or for caesarian operations.

Increasing Emergency Obstetric Care: Providing a basic package of services at Primary Health Centres and at Rural Hospitals. I would like to hear your comments and advice
Fariyal Fikree, M.D.: The three pronged approach that you have listed is one that addresses the concerns voiced by others on this online discussion session on the social deteminant of health (the socio-cultural barriers) and health system. I assume that referrals and an efficient referral chain is also inclused in the package as well as monitoring and evaluation. The implementation fo this package of services in the most deprived states is where, from my perspecitve, the greatest challenge lies in its implementation.

Stephen Settimi
: Two Questions: (1) How important is scheduled antenatal care to reducing death rates? (2) Do you think that if we collapse the time it takes to render care that death rates will drop and does information and communication technology (ICT) offer a solution in doing that?
Fariyal Fikree, M.D.: Antenatal care is one impt component for saving lives but unfortunately evidence shows that the high risk approach in antenatal care has not achieved improvements in maternal mortality. The delay factor in seeking care is important but another facet is the readiness of the facility where the care is being sought. By readiness I mean trained personnel, equipment and supplies. ICT will help but is not sufficient.

Dr. Yamini Sarwal
: The women who need the emergency and essential obstetric care the most are paradoxically the ones who are the most deprived. What are your recommendations for dealing with this inequity?
Fariyal Fikree, M.D.: Advocacy at the policy level is a good approach in the context of equity and poverty reduction. Also, see my response to your earlier questions.

Omrana Pasha
: We have recently completed a cohort study in a lower-middle class neighborhood in urban Hyderabad and found pregnancy outcome rates as poor as they are for Pakistan as a whole. This is despite the fact that there was more than 80% facility-based delivery and 83% skilled attendance. Clearly, this has important implications for the use of these indicators as measures of improvement in maternal/ neonatal care. What second generation of indicators do you think should be explored to look at the access, availability and quality of pregnancy and delivery care?
Fariyal Fikree, M.D.: Great to see that you are checking in on the prb website. A quick answer but one that needs further discussion (when I am next in Karachi) is facility based audits for matnerla and newborn mortaltiy and morbidity (see paper in Lancet on this) and assessing the training programs for health personnel who serve in these facilities. I assume that adverse pregnancy outcomes did not reflect LBW and IUGR or did it?

Sadik Mohammed
: What I really do not understand is why we do not consider the issue of sustainability whenever we design or pilot interventions for reducing MMR. With this syndrom of trying out strategies for the sake of trying out and reporting success or best practices, can we reduce MMR and meet the set MDG?
Fariyal Fikree, M.D.: A very pertinent question and long overdue. The sustainability of health programs is vital for the long term but is also a development question. harmonization between the various players (donors, ministry of health, planning and finance and NGOs)and a long term strategic approach will I believe go a long way in achieving sustainability.

Adamu M. Garun Gabas
: What is the most effective way in which Local Community Based Organzations in poverty-striken environments can contribute to reduce death rates from Pregnancy and Childbirths in thier respective localities?
Fariyal Fikree, M.D.: by raising awareness at the grassroot level—recognizing danger sign and appropriate referrals and advocacy that saving women’s lives is a human rights and equity issue

Adrienne Allison
: What is the relationship between age of mother and maternal mortality?
Fariyal Fikree, M.D.: See my earlier response.

zofeen t. ebrahim
: Will it be possible to tell me specifically about the cost-effective measures that the govt of Pakistan can pursue in reducing maternal mortality? Where is the government failing? A Pop Council report said unsafe abortion was used as contraceptive measure. It is also a major reason for mortality/morbidity in Pakistan. How should the government address this issue?
Fariyal Fikree, M.D.: Unsafe abortion (hemorrhage and sepsis) is one of the four major causes of maternal deaths. Availability of family planning services is one approach in addition to raising communtiy awareness, skilled birth attendant and availabiltiy and accessibility of emergency obstetric care. Advocacy at the national and provincial levels to saving women’s lives as a human rights and equity isse is one important venue to be considered by NGOs and media.

Sadik Mohammed
: With out reducing poverty and increasing girls education our efforts to reduce MMR will not succeed. Do you agree?
Fariyal Fikree, M.D.: Not entirely. See my response to the question posed by Rahat Toohen.

Alberto Rizo
: Dear Dr. Fikree: Greetings from Colombia. We in this country record round 28,000 deaths/year for external causes. We say we still have high mortality ratios (round 75x 100.000 LB/yr). The death pattern is characetrized for a decreasing number of deaths in state capitals plus random episodes scattered year in, year out in villages and small towns. (The compound number of maternal deaths/year is close to 1,000)

State Governors as well as local authorities find hard recognizing that maternal deaths are important when they are concerned with public health problems such as violence. What strategy should we use to bring safe motherhood into the screens of decission makers? Alberto Rizo, MD, MPH President, Colombian Academy of Public Health
Fariyal Fikree, M.D.: It is heartening to read your question as the MMR from Colombia is significantly less than from other developing countries. I would say advocacy … a concerted effort to build on the three paradigms of saving women’s lives is a developemnt, human rights and equity issue. Hence, needs to be center stage in any poverty reduction and development program especially among the rural and most deprived segments of Colombian society.

Saadatu Mohammed
: I am writting from a country where marternal death has become order of te day. hardly day passes by without a woman dying. The government has refused take Health issues with concern. No hospitals no trained personnel most of this birth is been attended by traditional birth attendant. pls tell me what need to be done our mothers are dying.
Fariyal Fikree, M.D.: For the governent to recognize matneral deaths and pay serious attention is the need for a concerted effort by NGOs and media on advocacy … that saving women’s lives is a development, human rights and equity issues …. the media needs to be galvanized to write articles and talk shows on thsi issue as this will then bring it to the attention of the policy makers.

Omrana Pasha
: You have mentioned skilled attendance as one of the major factors in reducing MMR. We have recently completed a study in an urban middle-class neighbourhood in Hyderabad. Of the 1300 women we followed through pregnancy, >75% delivered in hospitals and were attended by a physician. However, both maternal and neonatal outcomes were no better than noted for Pakistan as a whole. Do you think that using “skilled attendance” as an indicator of maternal-newborn care is useful? Clearly the quality of the care provided by the skilled attendant also needs to be looked at closely. Your thoughts?
Fariyal Fikree, M.D.: Definitely OP … in my frequent visits to Pakistan competency based training for midwives is the mantra that I have been repeating frequently. For physicians to provide maternity services in the current scenario where the MBBS doctors get minimal if any hands on maternity service trainign directly impacts on the quality of care. Facility based audits for matenal and newborn mortaltiy adn morbidity will shed light on those quality fo care indicators.

Sherif Arafa
: In your opinion, Do you think that medical students can join the healthcare workforce for maternal health education intheir comuinties? At least to compensate the shortage of trained healthcare providers in this vital section (Health Education.
Fariyal Fikree, M.D.: From my perspective, community health workers can be trained to provide the health education needed.

Omrana Pasha:
A related question about quality of care is that some of the hospital delivered women and their babies are also seen to be suffering from sepsis with multi-drug resistant organisms. How can we advocate for more care when regulation of the quality of health care is at best rudimentary in most high risk settings?
Fariyal Fikree, M.D.: Your question relates to the second generation of risk factors – and quality fo care. The need for effective monitoring of facility based tasks including indiscrimiante use of antibiotics is one of training and regulation. Why, for example, will you prescribe antibiotics judiciously but not the doctors who were in your study. Food for thought and how to address this – as you mentioned regulation will not do that so what will – incentives, training. My leaning is training including in-service.

Omrana Pasha
: We often speak of family planning in relation to improving maternal outcomes. But clearly maternal depletion through frequent pregnancies has adverse effects on the baby. What is the evidence for improved newborn outcomes with better birth spacing?
Fariyal Fikree, M.D.: A paper in Studies in Family Planning (a couple of years ago) was on exactly this topic. OP … dont know whehter you ahve seen this as well as I think one of my papers on IUGR. Will get back to you next week – in case I dont remind me on email

Kidza Yvonne Mugerwa
: The newest approach in Uganda today is formation of a women parliamentrian’s group specifically for prevention of maternal mortlity. they are working in close collaboration with the national association of obstetricians and gynecologists. We are very optimisitic about this, but again we do not know how beneficial such actions are. Do you have knowledge of such successful movements and are there any lessons learned on things that they should concentrate on or avoid in order to achieve maximum impact?successful
Fariyal Fikree, M.D.: From my experience, this is an excellent policy advocacy format. It has been shown to be successful in Honduras.

Saras Ganapathy
: There is a lack of good data on maternal mortality, especially in countries like ours. I wonder how effectively we can design interventions in the absence of this kind of information. Would like your perspective on this.
Fariyal Fikree, M.D.: To design interventions does not mandate the need for maternal mortality data in low resource countries. The level of maternal mortality will be high (above 200 per 100,000 live births) and the cost-effective interventions are known (see dcp2.org the chapter by Wendy Graham and the Lancet series on maternal survival). Monitoring and evaluation including trend analysis is what needs to be set-up as part of the intervention. An efficient and effecitve health information systems (the health metrics network is working on this) is necessary and from my persepctive should be a part of the intervention design.

A. L. Mukulu: Why is maternal mortality not responsing to the many safe motherhood/RH programmes currently in place? Are yhet out of focus?
Fariyal Fikree, M.D.: No the Safe Mothehood/RH programs are not out of focus. the need is for significant more emphasis and adovcacy on the issues that impact Safe Motherhood … saving women’s lives is a devleopment, human rights and equity issue … and hence the poverty reduction strategies and human right angle need to stress Safe Motherhood in its advocacy. Notwiethstanding these comments, the need for a concerted effort by the media to highlight the relationshiop b