(May 2008) Each year millions of women die needlessly as a result of pregnancy or childbirth. Maternal mortality is now a rarity in most developed countries, yet worldwide, a woman dies every minute from a pregnancy-related cause. The United Nations has challenged countries to reduce their maternal mortality by three-quarters between 2000 and 2015 (Millennium Development Goal #5), but many appear unlikely to meet this goal unless they receive help, especially within South Asia and sub-Saharan Africa. What is being done to marshal the financial resources and political commitment necessary to ensure safe motherhood around the world? Can we do more?

During a PRB Discuss Online, Theresa Shaver, director of the global secretariat of the White Ribbon Alliance for Safe Motherhood, answered participants’ questions about the challenges encountered and successes enjoyed by a major international effort to increase resources to save mothers’ lives.

Thank all of you for your questions and discussion on this important topic. Dr. Shaver was not able to answer all of your questions here in the time allotted. You can contact her through the White Ribbon Alliance (www.whiteribbonalliance.org).

May 8, 2008 1 PM EST

Transcript of Questions and Answers

Anand Bhat: Hello, I am a national officer for the American Medical Student Association, an organization representing 68,000 medical students. Our global health committee has done work on HIV/AIDS and PEPFAR, but does not have much experience advocating for policies to reduce maternal mortality. We are strongly considering getting behind this cause. We would like to know in what way AMSA could help in this cause. Are there any CAMPAIGNS going on or LEGISLATION in Washington that AMSA could help out with. We are planning our goals for next year between now and June and we need guidance.
Theresa Shaver: Hi, We would love for you to join us. In the White Ribbon Alliance for Safe Motherhood we believe everyone can “Play your Part”. If you go to our web site – www.whiteribbonalliance.org your association can get involved with the H.Res., which “recognizes maternal health as a human right” and calls upon the US government to “make a stronger commitment to reduce maternal mortality at home and abroad through greater financial investment and participation in global initiatives.” We look forward to you joining us! Theresa

Otula Owuor: Efforts towards Safe Motherhood have been complicated by increased violence against women in conflict zones of eastern and central Africa- Uganda, Kenya, Congo, Burundi etc- where rapes and even abduction of school girls is widespread. Any ideas on how this trend can be curbed?
Theresa Shaver: In 2007 through the Health Policy Initiative I worked with Emily Sonneveldt and the Reproductive Health Response in Conflict (RHRC)Consortium on a study titled “Understanding Operational Barriers To Family Planning Services in Conflict-Affected Countries: Experience From Sierra Leone.” The findings from this study can be accessed through the RHRC Consortium who have a wealth of information about these issues. The other group that is a resource is the Inter-agency Working Group on Reproductive Health in Refugee Situations (IAWG). These are wonderful consortiums and working groups who have country examples of best practices and what has worked to address these issues. Continuing to work in partnership and sharing what we know as best practices and holding governments accountable I believe can help curb this this terrible trend. Thank you for your question. Theresa

Anthony Bugembe: In some areas especially in rural communities in Sub-saharan Africa, a good number of people have faith in traditional birth methods and traditional birth attendants. Shouldn’t policy makers consider promoting, improving and making this alternative safer to pregnant women alongside the modern day options (hospitals and other health units)?
Theresa Shaver: This has been an ongoing debate for many years with limited aspects being studied throughly. One thing to always keep in mind when obstetrical complications arise, TBA’s can not handle the emergency and are often not a part of any referral system. There are some promising approaches at the community level. One being the home based life saving skills approach championed by the American College of Nurse Midwives – www.midwife.org/news.efm. For detail study on TBA and pregnancy outcomes please reference the article by Lynn Sibley and Theresa Ann Sipe -Titled “What can a meta anaylsis tell us about traditional birth attendant training and pregnancy outcomes?” Thank you for your question. – Theresa

sbyadawad@sify.com: Increased institutional deliveries could save the lives of more mothers and children. It is the common notion that most of the doctors go for cesarean operation instead of normal delivery and charge exorbitantly for their own benefit. It discourages some mothers to go for hospitals. How does the notion be removed and how to make institutional deliveries more accessible to poor and marginalized people?
Theresa Shaver: This is an issue of increasing concern for all the professional associations, such as FIGO, ICM, ACOG, ACNM, etc. There are studies that are coming out indicating an increase in cesarean sections and overmedicalization of births. Monitoring of the percentage of births that end in a cesarean section is occurring in a number of countries with close anaylsis to wealth quintiles to determine whether these are the result of emergencies or planned by the wealthier quintiles. Please refer to the websites of the professional associations for more information on this topic. Thank you. – Theresa

Diego Iturralde: In your opinion does, is there evidence to suggest that impoverished communities (like those in sub-Saharan Africa) can benefit in terms of reduced maternal mortality rates by receiving conditional cash transfers? If not how does one inculcate good maternal health practices in impoverished communities which more often than not are also poorly educated communities too.
Theresa Shaver: There are a number of different cash transfer programs underway including voucher systems, provider pay for performance, referral transfers, and cash for facility deliveries. At this early stage, there is not enough evidence on reduced maternal mortality, though increases in facility deliveries have been documented. The verdict is still out but this is something to watch as a promising approach. Thank you – Theresa

Theresa Shaver: There is significant evidence that health systems need to be in place to really reduce maternal mortality. However, there are some promisig interventions to address specific causes of maternal death in resource constrained countries. For example, community based family planning programs as essential, life-saving, and feasible in countries with poor health systems. Also, interventions for treatment of postpartum hemorrhage at the community level. You can reference the excellent work that PATH is doing through the Prevention of Postpartum Hemorrhage Initative (www.path.org/projects/preventing-postpartum) and studies by JPHIEGO. Also as referenced in an early question, home based life saving skills through the American College of Nurse-Midwives (www.midwife.org/news.efm) Thank you – Theresa

anna leah sarabia: How can the UN convince intl donor countries to put in more funds into projects to save mothers’ lives, as much as they fund peace and war reconstruction projects?
Theresa Shaver: This is very much at the heart of the WRA’s advocacy agenda—that maternal mortality must be on the agenda of all economic development partners. Please visit our website: www.promisetomothers.org to learn more about the framing of these messages. For example, we know that the economic losses to the world by not addressing maternal mortality are far greater than the economic investment required to reduce these needless deaths. On the Promise to Mothers Lost campaign, we will be pressing for these commitments and investments by global and national leaders.Please join us. Thank you – Theresa

Vijayan K Pillai: Have NGOs in developing countries contributed to reduction in MMR? If not,what can be done effectively by NGOs to reduce MMR.
Theresa Shaver: NGOs have a critical role to play in reducing maternal mortality. In particular, NGOs at the community level play a major part in addressing the first two delays – through their work in addressing birth preparedness and complication readiness and different transport schemes. One of the other challenges, not just for NGOs, but larger international bodies is actually measuring MMR effectively. There are some promising tools that have been developed by Immpact—please visit: www.maternal-mortality-measurement.org. Also, NGOs are tremendously important in advocating for adequate resources, supportive policies and programs, and holding governments accountable to promises made. Thank you – Theresa

T.Pugalenthi: Dear Sir, I would like to know the maternal mortality of different years 1901 – 2008. What are the [main] causes for MMR in developing and developed countries?
Theresa Shaver: Global estimates for maternal mortality ratios:

1983: 500,000 (Royston and Armstrong, WHOP)

1990: 509,000 (Hill and Stanton, WHO, UNICEF 1996)

1990, revised: 585,000 (above reference)

1995: 515,000 (Abouzahr and Waardlow, WHO/UNIEF/UNFPA, 2001)

2000: 529,000 (WHO/UNICEF/UNPFA, 2003)

Main causes globally:

–severe bleeding (24%)

—eclampsia (12%)

—unsafe abortion (13%)

—infection (15%)

—obstructed labor (8%)

—other direct causes (8%)

—indirect causes (20%)

Thank you – Theresa

Urvi Shah: Hello Dr. Shaver, The Indian government is committed to reduce MMR & IMR. One of the initiatives to this end has been Public -Private Partnership (PPP)by paying empanelled pvt obgyns to provide obstetric care to those women who cannot afford the private services and who are in most need of good natal care particularly in the rural areas. The initial results from the pilot scheme in a western state of the country are encouraging in saving maternal & newborn lives. Simultaneously, the government is also increasing public spending by strengthening its huge health network to provide EmOC. However, much more needs to be done at the community level to improve levels of anemia among young girls and pregnant and non-pregnant women and in identification of high risk pregnancies by grassroots healthworkers. No single effort alone will workl What is needed is a dovetailing of already existing schemes which are implemented with the right political vigor. What, according to you, are some ways to achieve this?
Theresa Shaver: I agree fully that it takes efforts at multiple levels and by diverse stakeholders. We are committed to this approach as an alliance and encourage you to join the White Ribbon Alliance in India. Contact details can be found at www.whiteribbonalliance.org. Thank you – Theresa

Joseph Dwyer: We have been saying that “Each year millions of women die needlessly as a result of pregnancy or childbirth” for a couple of decades now. I understand that proven practices to prevent the majority of maternal deaths are now known. What are the one or two key factors, in your opinion, that these proven practices are not being scaled up. It doesn’t seem that it’s a lack of clinical or medical knowledge.
Theresa Shaver: It is agreed we know what to do and how to do it, what is lacking is the political will and commitment. That is why we are engaged in both a global and national level advocacy campaign to hold leaders to these global commitments and endorsements to ensure that the resources, systems, and workers are a priority. This is potentially an incredible time for global commitments and resources to really be put behind these proven practices. Jeremy Shiffman has done an excellent analysis of why maternal health has not received the needed political commitment, why this commitment is the missing link, and what some key factors are. His work can be found through the Center for Global Development. Thank you – Theresa

Kofi Awusabo-Asare: What do you think should be done to reduce ‘expert’ advice from the west on MMR and identify home-based solutions? This is because some of the suggestions tend to be unsustainable. Could you comment on the commitment that African governments should put in to reducing MMR?
Theresa Shaver: On your first question, please reference my early answers related to community based approaches. On your second question, one key commitment for African governments is to commit to the Abuja Declaration of 15% of government budgets to be allocated to health. This is critical step in strenghening the health systems and providing quality maternal health services. Another important strategy: the African Road Maps for accelerating the reduction of MMR, which include crucial integration of family planning, malaria, HIV/AIDS, child health with maternal and newborn services. Thank you. – Theresa

Dr. James Akpablie: One key challenge to reduce the MMR in Ghana is the inadequate, demotivated health workers. I want to set up an alliance of stakeholders to advocate for increased support [for] more trained, motivated health force especially doctors and midwives. Is there any way the PRB can help me? I work in the northern regions of Ghana, the most deprived.
Theresa Shaver: This issue is a crticial one across Africa. The White Ribbon Alliance in Tanzania has taken this on as its primary advocacy issue – including increasing the number of qualified workers, improved training, incentives, supportive work environment, etc. More information on their work can be found on the WRA website www.whiteribbonalliance.org. In addition, we have developed a guide based on lessons learned in building, maintaining and sustaining alliances. This is also available in the resource section on the WRA website. Thank you – Theresa

Taraneh Salke: 1- Considering the established fact that preventing unwanted and multiple pregnancies reduces MMR; and that prevention is available through low cost measures requiring lower level of skills compared to treatment, why do you think the international community is not more focused on this one proven way? 2- Considering that in most developing countries women are powerless and men are the ones making most decisions including decisions regarding sex, family planning and fertility; and that in many societies informing, educating and bringing men on board is a pre-requisite to change and to reach and help women, why do you think more effort is not put into programs that focus on men and encourage male involvement in reproductive health, family’s health, and the health of the community?
Theresa Shaver: 1- One of the contributing factors may be the fact that many donor agencies have seperate pools of funding and seperate strategies for family planning versus maternal and child health. Consequently, it has been challenging to integrate the two, despite the evidence that FP is integral part of MNH programs. 2-I agree there has not been enough emphasis on male involvement, but there are many organizations that are working on this and having success. One example is Save the Children’s work on approaches to involving men and religious leaders in family planning and maternal and newborn health. For further information, you can visit the Save the Children website. Thank you – Theresa

Rahat Bari Tooheen: Alliances will go a long way towards solving the crisis. But the most pressing issue is the social attitude towards mothers. What measures can be taken to address this?
Theresa Shaver: By working in an alliance, we found there are very positive measures being taken to support women during pregnancy and childbirth. By working with diverse stakeholders, such as civil society, international organizations, faith based organizations, professional associations, and local organizations and government, we can create empowering and supportive environments and utilize innovative strategies such as “social watch” approaches to monitor the quality of care, including the treatment of women and family involvement, at the facility level. There are also innovate approaches at the community level. It is our hope that by having involvement and collective action from the household to the district to the national level will improve the overall social attitudes towards women.

Ernest Nettey: Countries such as Ghana are more preoccupied with economic development, such that issues such as maternal mortality don’t receive the attention required. What are the factors that prevent international financial institutions such as the IMF and World Bank from being more active in leading the campaign to integrate maternal mortality into development plans?
Theresa Shaver: We are working on exactly this issue—how to engage major economic development instutions in addresing maternal mortality – it is an issue of economic development. We had a very successful engagement with the IMF and World Bank during the spring meetings of the IMF/World Bank Development Committee in Washington DC. One of the factors that has contributed to these institutions not being on the forefront of this issue has been parallel programming – and this is something that the World Bank in particular is striving to address through a health systems approach that puts maternal and child health at the heart of the health system. We applaude this progress – and will continue to engage these institutions and their leadership and we encourage you to also do that at the country level. Also note that Ministers of Finance from developing countries have an active voice and important role both in influencing these global institutions as well as making decisions and commitments at the national level (such as Abuja Declaration). Please join with us. Thank you – Theresa

Visit the web page for White Ribbon Alliance for Safe Motherhood: www.whiteribbonalliance.org