MDG5 Digest 2

MDG 5 is the one at most risk of not being met by 2015. Why is it falling behind?

There are several reasons why MDG5 is falling behind.

Firstly, there is no “magic bullet” to reduce maternal mortality.  While there exist simple and cheap solutions such as oral rehydration therapy to treat the major cause of child deaths in developing countries, treatments and interventions necessary to treat the major causes of maternal mortality are expensive and can only be provided in a health facility by health professionals.  For example, a woman with postpartum haemorrhage (massive bleeding following delivery) will need a blood transfusion.  A surgical intervention is necessary for a woman in obstructed labour.  Providing these treatment and intervention is difficult especially in rural areas because, for various reasons, not many women use a health facility to deliver babies:  there are not enough health facilities and qualified health professionals in rural areas;  and financial constraints mean that many women choose not to use a health facility but deliver at home without professional assistance.  As a result, women often come to a hospital too late to be treated when complications of childbirth occur during home birth.

-       What about providing clean delivery kits to women for home birth in rural communities?  Would that help?  - It might help to reduce the incidence of infection, but will not help to reduce the incidence of other causes of maternal death such as haemorrhage, hypertensive disorders or obstructed labour.

-       What about training of traditional birth attendant (TBA) where there is no midwife or obstetrician?  -  TBAs can be the source of emotional support to women during home birth but they are not capable of treating complications during childbirth.  Even if they recognize a complication, they may not make a prompt referral to a health facility because they work independently and are not part of a health system.

-       Will providing adolescents with health education such as information relating to abortion services help reduce maternal mortality?  -  Maybe or maybe not. There are many ‘good ideas’ that may or may not help reduce the MMR, and health education for young adolescents may be one of them: girls who have access to information may be able to have healthier pregnancies but on the other hand, they may not always have the power to make their own decisions about reproductive health

Second, the issue of maternal mortality has not been given a high level of political priority because maternal mortality is a women’s issue and women’s status is often low in many developing countries.  Grassroots organizations of other health issues have been more successful.  For example, victims and survivors of HIV/AIDS have been successful in raising awareness.  But grassroots organizations have not been able to mobilize to press international political authorities to address maternal mortality at the global level because victims of maternal mortality can’t speak for themselves and survivors of pregnancy-related complications are powerless women and their voices are often unheard in their societies.

The lack of a clear strategic focus within the safe motherhood community is partly responsible for the slow progress toward MDG-5.  From the 1970-1980s, the safe motherhood community promoted antenatal risk screening (so that high-risk women could  be referred to a health facility for delivery) and the training of traditional birth attendants.  Concerns were expressed in the mid 1980s that these two approaches were not sufficient to prevent maternal deaths.  A strategic change took place in the 1980s to promote the need for access to emergency obstetric care in the event of complications at childbirth.  (UNFPA site for more information about Emergency Obstetric Care http://149.120.32.2/mothers/obstetric.htm )  Some advocates emphasized that its importance had been exaggerated, and the role of skilled birth attendants had been neglected.   After over three decades of trials and failures of various strategies, a consensus has been gradually building that women need both skilled birth attendance at birth and access to emergency obstetric care in case of complications.

Measuring the MMR is notoriously difficult.  In countries with a high MMR, a good civil registration system does not usually exist to record the number and causes of deaths.  Instead, modelling techniques are often used to estimate the MMR.  The difficulty in obtaining an accurate MMR may have hampered many countries from monitoring the progress toward MDG 5 and the national and international safe motherhood communities from advocating for political attention and resources necessary for achievement of the MDG -5.

However,  recent research from the University of Washington, reported in the Lancet,  seems to suggest that the MMR is declining globally, from 526 300 deaths in 1980 to 342 900 in 2008 (https://www.who.int/pmnch/topics/maternal/20100402_ihmearticle.pdf).  The investigators of the University of Washington used methodologically-improved modelling techniques to estimate the MMR for 181 countries.  There are fairly large uncertainty intervals in these estimates and the results should be interpreted cautiously.  Nonetheless, the declining trend in the MMR confirms that the efforts of the international safe motherhood community are paying off and continued investments are crucial for a further reduction in the MMR.

Atsumi Hirose, August 2010