Maternal Mortality& the MDGs

Deborah MaineProfessor, International Health

Boston University, School of Public Health

MDG Goal: Improve maternal health

Target: Reduce the MM Ratio by 3/4 by 2015

Indicators: Maternal mortality ratio Proportion of births attended by skilled

health personnel

The MDG for MM

Is it realistic ?

History

MMRs

Sri Lanka: 1947 -- 1500

1960 -- 250

1980 -- 100

Malaysia: 1950 > 500

1975 < 100

To reduce MM …

Need to understand the epidemiology of maternal mortality [MM]

A counterintuitive phenomenon Many “obvious” approaches don’t work,

e.g. risk screening, training TBAs

Maternal Mortality

Region MM Ratio Lifetime Risk

1 in …

Africa 830 20

Asia 330 94

Latin America 190 160

North America 17 2,500

World 400 74

Causes of Direct Obstetric Deaths

The “Big 5” Hemorrhage Infection Hypertensive diseases Obstructed labor Unsafe induced abortion

The Way Programs Should WorkEvidence

Interventions

Indicators

Strategy

Interventions

IndicatorsStrategy

Assumptions

The way it often works

Assumption

If we just take very good care

of pregnant women,

few will develop serious

obstetric complications.

History: Prenatal Care

1910-15 first clinics in UK (and US) By 1930, 80% pregnant women in UK

have prenatal care But maternal mortality did not decline

TBAs & “Clean Delivery”

In Matlab, Bangladesh, TBAs were trained to use clean delivery practices.

The did use these practices, but maternal deaths due to infection

did not decline.

Assumption

Through prenatal screening,

We can identify the women

who will need medical care

The Math of Prediction

It works for groups

but not for individuals.

Example: Matlab, Bangladesh1968-70

Maternal Age 10-14 20-29

MM Ratio 1770 450

Relative Risk 3.9 1

# Births 509 11,286

# Deaths 9 51

Example: United Kingdom1985-87

Maternal Age 20-24 45+

MM Ratio 37 188

Relative Risk 1 5.1

# Deaths 24 2

Risk and Prediction (cont.)

A big risk in a small population =

few deaths

A small risk in a big population =

many deaths

In Short ...

Once a woman is pregnant

most serious obstetric complications

cannot be predicted or prevented,

but they can be treated.

So

All pregnant women

need access to

emergency obstetric care

(EmOC)

Sri Lanka & Malaysia

How did they do it ? Expanding access to effective

maternity care by midwives and doctors Improving utilization and quality of care

with emphasis on making life-saving care free.

The World Bank, 2003

Assumption

EmOC is

“Hi-Tech”

Signal Functions of Basic EmOC :

Parenteral antibiotics, oxytocics, anticonvulsants

Manual removal of placenta Removal of retained products Assisted vaginal delivery Neonatal resuscitation (new)

Should be at health centers

Signal Functions of Comprehensive EmOC:

All Basic EmOC functions Blood transfusion Surgery (c-section)

Should be at District Hospitals

EmOC is not “Hi Tech”

It is mostly 1950s medicine !

EmOC is the foundation

Emergency Obstetric Care

SkilledAttendant Referral

Risk Screening

Social Mobilization

Waiting Homes

TBA Training

AntenatalCare

Assumption

EmOC is too expensive

Community-based workers

are more affordable

A cost-effectiveness exercise: unit cost

0 5000 10000 15000 20000 25000 30000 35000

Upgrading 1District Hospital

Upgrading 1Health Center

Training etc, 1MCHW

PROGRAM

Dollars

$350

$10,000

$30,000

Cost (cont.)

Suppose, per district, there are:

100 MCHW s 4 health centers 1 district hospital

Estimated program cost (in $000s)

0 10 20 30 40 50

Upgrading 1District Hospital

Upgrading 4Health Centers

Training etc, 100MCHWs

PROGRAM

Dollars

30

40

35

Estimated obstetric deaths prevented (%)

0 10 20 30 40 50 60

District hospital

Health centers

MCHW training

PROGRAM

50

Percent

25

15

Estimated cost per death averted ($000)

0 200 400 600 800 1000

Upgrading 1District Hospital

Upgrading 4Health Centers

Training etc, 100MCHWs

PROGRAM

$580

$845

$217

In short …

Something that is not effective

can never be cost-effective.

Measuring Progress:

Are we measuring the right things?

The Way It Should WorkEvidence

Interventions

Indicators

Strategy

But sometimes …

MDG Goal: Improve maternal health

Target: Reduce the MM Ratio by 3/4 by 2015

Indicators: Maternal mortality ratio Proportion of births attended by skilled

health personnel

Promoting SBAs

What is the evidence base

for this policy?

SBAs and MMR, 170 countries

R2 = 0.6124

0

500

1000

1500

2000

2500

0 20 40 60 80 100% Skilled Attendant at Delivery

Mat

ern

al M

ort

ality

Rat

io

(per

100

,000

live

bir

ths)

Country n=170

Source: Safe Motherhood Initiative website and Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA (2001)

SBAs and MMR, 50 Countries with MMR>400

R2 = 0.0818

0

500

1000

1500

2000

2500

0 20 40 60 80 100

% Skilled Attendant at Delivery

Ma

tern

al M

ort

alit

y R

ati

o

(pe

r 1

00

,00

0 li

ve

bir

ths

)

Country n=50

Source: Safe Motherhood Initiative website and Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA (2001)

This shows:

the relationship between

delivery by SBAs

and MMR

is not strong

for high-mortality countries

Source: Saving Lives: Skilled Attendance at Childbirth, W. Graham, 2000.

Source: Saving Lives: Skilled Attendance at Childbirth, W. Graham, 2000.

This shows:

the relationship between

delivery by midwives

and reduced MMR

is not clearcut –

probably due to regional variation in what midwives are trained and permitted to do.

Skilled Attendants need to be part of

a functioning health system

To Be Effective

Sri Lanka, 1970s >

HealthFacilities

SBAs

Many Proposed Programs

HealthFacilities

SBAs

In Reducing Maternal Deaths

There are really only 3 issues: COVERAGE OF SERVICES QUALITY OF CARE UTILIZATION OF SERVICES

The Road toMaternal Mortality Reduction:

Shortcuts or Detours ?

Pseudo-Interventions

“Safe Birth Kits”: No evidence of effectiveness in reducing maternal deaths, but consume effort, attention and funds.

Advocacy for Advocacy: If not linked to programs, advocacy can be a detour.

1-Complication MM Programs

Example: Home-based prevention of post-partum hemorrhage (PPH)

Hemorrhage = 25% of maternal deaths

Perhaps ½ preventable = 12.5%

Semi-Skilled Attendants

If you leave the skills out of

Skilled Birth Attendant

what do you get?

Institutional Delivery Targets

Easy to measure, but

no indication of quality of care

You can reach the target

But miss the goal !

“In the Meantime …”

If we don’t get started now

fixing health systems

in 20 years we will still be

in the meantime.

General Lesson:We must build health systems Need a strong evidence base Training and equipment are never

enough Management systems are crucial Even skilled personnel need support Learn from expensive failures