Preventing Maternal Mortality

Resources Topic 3 Evidence based solutions within Health Services

We now understand that pregnancy and childbirth forms an exceptionally vulnerable period in any woman’s life, during which complications may arise, often without options for primary prevention. Health care services serve to enable women to arrive at pregnancy and childbirth in a good condition, to aid in avoiding any undesired pregnancy and childbirth, and to ensure vigilance for detection of complications as well as appropriate and timely treatment for any complications which may arise.

The Global Strategy for Women’s, Children’s and
 Adolescents’ Health (2016-2030) is an important resource and key excerpts can be seen here (full document can be downloaded here) contains important information:

Figure 1 on page 17 of this strategy provides a good overview of intervention packages within the health care system to contribute to reduced maternal mortality:

It shows how:

• Pregnancy care, childbirth care and postnatal care: antenatal care, childbirth care;
safe abortion and post-abortion care;
prevention of mother-to-child transmission of HIV;
management of maternal and newborn complications; postnatal care for mother and baby; extra care for small and sick babies

• In addition, it clearly states the interventions required to strengthen adolescent and women’s health, before pregnancy, which helps to lower maternal mortality indirectly.

• And it gives attention to child health, so that after surviving pregnancy and childbirth women indeed have a healthy child as ultimate outcome, which also aids to reduce maternal mortality indirectly.

• The health system enablers mentioned are also crucial for the capacity to deliver any of these interventions and go beyond words in detailed policy documents: policies for universal health coverage; sufficient and sustainable financing; health workforce supported to provide good-quality care everywhere; commodity supply; health facility infrastructure; community engagement; mainstreaming emergency preparedness.

The figure also has a good list of multisector enablers, which we will meet again in Topic 4.

Annex 2, page 88-91 in the same strategy, provides a good overview of evidence-based health interventions for women’s, children’s and adolescents’ health, which includes an exhaustive list of interventions during pregnancy, childbirth, postnatal period (mother and child), as well as interventions before and outside of pregnancies.

The three most obvious and important health care interventions to contribute to reducing maternal mortality are modern contraceptives, skilled birth attendance, and emergency obstetric care.

• Modern contraceptives: Family planning: a global handbook for providers is a handbook, published by the World Health Organization (WHO) and the Johns Hopkins Bloomberg School of Public Health's Center for Communication Programs' INFO Project, brings together the best available scientific evidence on family planning methods. It is too large to download here, but the link takes you to a summary and the ability to download it yourself.

• Skilled birth attendance: here we could include this paper: The scale, scope, coverage, and capability of childbirth care, (from the 2016 Lancet series). The summary states:  "All women should have access to high quality maternity services—but what do we know about the health care available to and used by women? With a focus on low-income and middle-income countries, we present data that policy makers and planners can use to evaluate whether maternal health services are functioning to meet needs of women nationally, and potentially sub-nationally. We describe configurations of intrapartum care systems, and focus in particular on where, and with whom, deliveries take place. The necessity of ascertaining actual facility capability and providers' skills is highlighted, as is the paucity of information on maternity waiting homes and transport as mechanisms to link women to care. Furthermore, we stress the importance of assessment of routine provision of care (not just emergency care), and contextualise this importance within geographic circumstances (eg., in sparsely-populated regions vs dense urban areas). Although no single model-of-care fits all contexts, we discuss implications of the models we observe, and consider changes that might improve services and accelerate response to future challenges. Areas that need attention include minimisation of over-intervention while responding to the changing disease burden. Conceptualisation, systematic measurement, and effective tackling of coverage and configuration challenges to implement high quality, respectful maternal health-care services are key to ensure that every woman can give birth without risk to her life, or that of her baby."

• Emergency obstetric care: this article is a good example of EmOC evaluation: Distribution and quality of emergency obstetric care service delivery in the Democratic Republic of the Congo: it is time to improve regulatory mechanisms. Here it is also important to notice that EmOC is more than only performing caesarean sections: see: Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis  and Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide from the 2016 Lancet series.

One of the key resources to be able to provide these health care interventions adequately are midwives, when properly trained, supported, supervised, and empowered. The state of the world’s midwifery reports provide very useful information. The State of the World's Midwifery: Analysis of the Sexual, Reproductive, Maternal, Newborn and Adolescent Health Workforce in East & Southern Africa.

A topic which in this context is coming up more recently is the provision of quality and dignified care in maternal health care. Though not directly related to maternal mortality, it does influence on demand and usage of health services. See for example this paper: Community and health system intervention to reduce disrespect and abuse during childbirth in Tanga Region, Tanzania: A comparative before-and-after study.

While the provision of health care services to aid in the reduction of maternal mortality is often seen as a public health matter, it can also be seen as a matter of human rights. The United Nations Human Rights Office of the High Commissioner, in its section on Sexual and reproductive health and rights, states: "Women’s sexual and reproductive health is related to multiple human rights, including the right to life, the right to be free from torture, the right to health, the right to privacy, the right to education, and the prohibition of discrimination. The Committee on Economic, Social and Cultural Rights and the Committee on the Elimination of Discrimination against Women (CEDAW) have both clearly indicated that women’s right to health includes their sexual and reproductive health. This means that States have obligations to respect, protect and fulfill rights related to women’s sexual and reproductive health....Despite these obligations, violations of women’s sexual and reproductive health rights are frequent. These take many forms including denial of access to services that only women require, or poor quality services, subjecting women’s access to services to third party authorization, and performance of procedures related to women’s reproductive and sexual health without the woman’s consent"Setting this in the context of inequality, the Office also states in a pamphlet on Maternal Mortality and Morbidity accessed from the page Sexual and reproductive health and rights: "According to the World Health Organization, “The maternal mortality ratio in developing countries in 2013 is 230 per 100,000 live births versus 16 per 100,000 live births in developed countries. There are also large disparities within countries, between women with high and low income and between women living in rural and urban areas.” Often seen as a public health concern, the issue of maternal mortality and morbidity must also be understood as a matter of human rights." More information on this perspective may be found in this paper 'An intersectional analysis of maternal mortality in Sub-Saharan Africa: a human rights issue'.