(April 2005) Among the development challenges that the international community hopes to tackle in the next decade, reducing the death and suffering associated with pregnancy and childbirth in the world’s poorest communities remains one of the most daunting.
Despite heightened attention to the issue in the last two decades, progress in reducing these deaths (the number of which is particularly difficult to estimate) has so far eluded governments. But the international community has renewed its commitment to the issue by setting a 2015 deadline for a significant worldwide reduction in pregnancy-related deaths and for improving maternal health globally.
Progress toward this and other UN Millennium Development Goals (MDGs) set by world leaders in 2000 will be weighed at a high-level session of the UN General Assembly in New York in September 2005. Discussions are expected to include a focus on ways of measuring the problem and on the most effective strategies for reducing maternal mortality.
Maternal Mortality Almost Exclusively a Developing Country Issue
Roughly 500,000 women die every year of risks associated with pregnancy and childbirth, with some 95 percent of the deaths in 2000 occurring in Asia (253,000) and sub-Saharan Africa (251,000). Four percent were in Latin America and the Caribbean, with less than 1 percent in more developed countries.1
Even though Asia and Africa have an almost equal number of these deaths, the risks are highest by far in Africa, which has a much smaller population than Asia. African countries struggle to provide health services for large, dispersed, mainly rural populations, and the average number of children per woman on the continent is close to six.2 An African woman has a 1 in 16 chance of dying in pregnancy or childbirth over her lifetime, compared with 1 in 94 in Asia. In Europe, where the average number of children per woman is less than two and medical care is readily available, only one in every 2,400 pregnant women dies of maternity-related causes.
Most maternal deaths result from excessive bleeding, infections, hypertensive disorders, obstructed labor, or complications from unsafe abortions. In many poor communities, women with pregnancy-related complications face delays in deciding to seek care, getting to the appropriate health facility, and receiving treatment once they get there. While UN agencies estimate that 15 percent of all pregnancies result in complications, predicting individual instances of these complications is difficult.3
Improving Health Systems is Part of a New Focus
Traditional efforts to reduce maternal deaths have included strengthening access to prenatal care, improving women’s nutrition, trying to identify high-risk pregnancies early, and training traditional birth attendants. However, none of these approaches has had a major impact on maternal mortality in developing countries.4
Lately, however, international thinking on how to stem maternal deaths has shifted from trying to predict and prevent complications to focusing on strategies for saving women’s lives once complications set in, particularly during the critical delivery period.5 The UN Population Fund explains the shift by noting that, although a greater percentage of high-risk women die of maternal complications, the greatest number of maternal deaths occurs among the vast majority of women who are considered at low risk.
For its part, UNFPA’s strategy to prevent maternal mortality includes having births attended by professional midwives, nurses, or doctors who can quickly recognize and manage complications and refer them appropriately. The strategy also includes giving women access to emergency obstetric facilities that can perform Caesarean sections and blood transfusions, remove the placenta, administer antibiotics, and carry out other emergency procedures.
Experts say this kind of strategy relies heavily on health facilities having the necessary supplies, working equipment, and trained personnel to save lives. However, these prerequisites are a major challenge for many cash-strapped developing countries. In addition, some analysts point out that strategies that include training and deploying skilled attendants and referring complicated cases to emergency facilities have rarely tried to find out whether the facilities even function.
As the UN Millennium Project’s Task Force on Child Health and Maternal Health puts it: “For hundreds of millions of people, a huge proportion of whom live in sub-Saharan Africa and South Asia, the health systems that could and should make effective interventions available, accessible, and utilized are in crisis—a crisis ranging from serious dysfunction to total collapse.”6 (The UN Millennium Project is an independent advisory body commissioned by the UN Secretary General to advise on strategies for meeting the MDGs.)
In a new report, the task force says that maternal mortality strategies should focus on building functioning primary health care systems that stretch from referral-level facilities to the community level. The task force also argues that such a system should have a number of important features:
- Emergency obstetric care should be available to all women who experience maternity-related complications.
- Skilled birth attendants (whether in facilities or communities) should form the system’s backbone.
- Skilled attendants for all deliveries must be integrated with a functioning district health system that supports and supervises them.
Some experts have noted that focusing on emergency obstetric care does not negate the importance of other kinds of activities, such as working with the community to encourage families to promptly seek care for women who are ill. Nor does it mean that all pregnant women need to deliver in medical facilities.
Using UN Goals to Measure Progress
The urge for new approaches is fueled by frustration with persistently high levels of maternal deaths in less developed countries. That urgency has increased in light of the need to measure countries’ progress toward the MDGs, which include a goal for improving maternal health with one time-bound and measurable target: a 75 percent reduction by 2015 of the 1990 worldwide maternal mortality ratio.
Health experts have been frustrated, however, by weaknesses in traditional ways of tracking maternal deaths. The two measures attached to the goal are the maternal mortality ratio and the proportion of births attended by skilled health personnel. Determining the maternal mortality ratio, usually defined as the number of annual maternal deaths for every 100,000 live births in a population, relies on accurate data on maternal deaths and their causes. But these data are difficult to come by for a variety of reasons: Many deaths occur outside of health systems and are not recorded; health workers may not always know the causes of death; collecting the data is costly; and calculating the numbers is complex.
To overcome these hurdles and move toward achieving the goals, some analysts and policymakers have focused on measures released in 1997 by UNFPA, the World Health Organization (WHO), and the United Nations Children’s Fund (UNICEF). Known as UN process indicators, these measures provide policymakers and those designing maternal health programs with new kinds of information.
While maternal mortality ratios point to levels and frequency of maternal deaths, the UN process indicators monitor the progress of health programs in reducing these deaths. According to the UN agencies that developed the indicators, the measures provide information that can help plan programs, highlight problems, and evaluate programs’ success.
The UN process indicators include the following:
- The number and distribution of emergency obstetric care facilities. To address problems related to timely access to care, the indicators suggest that every 500,000 people need at least one facility that offers comprehensive care and four that offer basic care. Basic care includes antibiotics, manual removal of the placenta, and assistance in vaginal delivery of the baby. Comprehensive care includes all these services as well as Caesarean sections and blood transfusions.
- The proportion of all births in emergency obstetric care facilities. Since an estimated 15 percent of all pregnant women develop complications, that percentage should be expected to seek emergency services.
- The met need for emergency obstetric care. All women with obstetric complications should be treated in emergency obstetric facilities.
- Caesarean sections as a percentage of all births. C-sections should account for not less than 5 percent and not more than 15 percent of all births in the population.
- The number of deaths among women admitted to the facilities with complications. Deaths should not exceed 1 percent of the women admitted, according to the UN guidelines.
While UN agencies do not recommend abandoning the maternal mortality ratio and other traditional measures of maternal mortality, they note that the process indicators can answer such important questions as why women are dying and how the deaths can be prevented. As noted by the World Health Organization report Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF, and UNFPA : “Further research is needed to identify cost-effective and reliable ways of measuring maternal mortality.”7
“Now is the time to take up the challenge,” adds Wendy Graham, the main researcher for the Initiative for Maternal Mortality Programme Assessment (IMMPACT), a research organization based at the University of Aberdeen in Scotland. “It has long been recognized that maternal health services are dependent on the functioning of the entire health system … Data are needed to ensure that the most effective and cost-effective intervention strategies for safe motherhood are integrated into essential service packages, and also to track the impact of the reform process using realistic and affordable information systems.”8
Yvette Collymore is a senior editor at the Population Reference Bureau.
- World Health Organization (WHO), Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF, and UNFPA (Geneva: WHO, 2004).
- Lori Ashford and Donna Clifton, 2005 Women of Our World (Washington, DC: Population Reference Bureau, 2005).
- WHO, Mother-Baby Package: Implementing Safe Motherhood in Countries (Geneva: WHO, 1994).
- Lynn Freedman et al., “Background Paper of the Task Force on Child Health and Maternal Health,” Millennium Project: Commissioned by the UN Secretary General and Supported by the UN Development Group (April 18, 2003).
- UN Population Fund (UNFPA), Maternal Mortality Update 2002: A Focus on Emergency Obstetric Care (New York: UNFPA, 2003).
- UN Millennium Project, Who’s Got the Power? Transforming Health Systems for Women and Children, summary version of the report of the Task Force on Child Health and Maternal Health (New York: UN Millennium Project, 2005).
- WHO, Maternal Mortality in 2000.
- Wendy J. Graham, “Now or Never: The Case for Measuring Maternal Mortality,” The Lancet 359 (Feb. 23, 2002): 701-704.