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Oct 24, 2009
What will it take to stop maternal deaths?
AUTHOR:Richard HortonSOURCE:The Lancet
The great conundrum of global health is the apparent resistance of maternal mortality to over two decades of vigorous campaigning and commitment by the safe- motherhood movement. The UN's 2009 report card on Millennium Development Goal (MDG) 5-between 1990 and 2015, to reduce by three quarters the maternal mortality ratio-concluded that "little progress" had been made, especially in sub-Saharan Africa where half (265 000) of all maternal deaths take place.
Why is this? The great advantage for diseases such as HIV/AIDS, tuberculosis, and malaria is that there are ready interventions available-antiretrovirals, directly observed therapy, and insecticide-treated bednets-which can prevent and treat disease. Optimism exists because these interventions might offer the prospect of disease elimination, even for the most resilient of epidemics. The international donor community has now recognised the deep inequity between the health-related MDGs. In a series of announcements this week at the UN General Assembly, further innovative financial commitments have been made by key donors-including the UK-to scale up action to achieve MDG 5. These pledges are welcome. But will they make the difference that is needed?
In 2006, the best available scientific evidence indicated that timing of maternal deaths is clustered around labour, delivery, and the immediate post-partum period; a health-centre intrapartum care strategy would be most likely to bring down rates of maternal mortality; and teams of midwives working in health facilities would do much to fill the coverage gap in maternal care. This facility-based approach to achieving MDG 5 has been the cornerstone of maternal advocacy. Empirical evidence has supported this strategy.
By 2007, a re-conceptualization of maternal mortality had taken place. The silo approach to global health was dissolving. In its place came the notion of a continuum of care, integrating strategies, resources, interventions, and outcomes for maternal, newborn, child, and reproductive health. The 2008 Countdown to 2015 report concluded that this linked strategy for maternal and child health would require multiple delivery approaches-in health facilities and in the community. A strengthened primary health-care system seemed especially effective at delivering improvements, perhaps being able to prevent as many as 20-30% of all maternal deaths.
The consensus around a purely health-systems strengthening approach to reducing maternal mortality has long held reign. But it has been challenged as too rigid and beyond the abilities of many low-income countries, where the burden of maternal deaths is greatest. A new report in The Lancet today, by Christina Pagel and colleagues, now shows that augmenting health-facility strengthening with improved drug treatment of post-partum haemorrhage (misoprostol) and sepsis (antibiotics)-via antenatal care, community health workers, and female village volunteers- could avert a third of maternal deaths annually. The poorest women would benefit the most from these interventions. A community approach to maternal mortality reduction, combined with a facility-based approach, would likely deliver substantial additional benefits. The mathematical model in today's report has the potential to transform attitudes to maternal health. We might now be able to contemplate donor-funded drug-delivery programmes, akin to those available for HIV/AIDS and tuberculosis, in addition to health-facility strengthening. Such a strategy might radically alter the prospects for pregnant women in low-income settings.
The main challenges to responding to these new data are financial and institutional. Although funding for maternal health has risen considerably since 2003, donor assistance is small as a proportion of total aid, is project based, volatile, and poorly targeted. Existing major global health initiatives-the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, for example-make only minimal contributions to maternal health. Given these omissions, some critics have called for a new global fund for MDG 5 and MDG 4 (on child survival). But the appetite to create new institutions and new vertical pools of financing is likely to be low at a moment of global economic fragility.
Instead we are left with two pieces of important evidence. First, disease-specific global health initiatives, while delivering many positive benefits, also have several unanticipated side-effects on health systems and do little to strengthen stubbornly resistant health predicaments, such as maternal mortality. Second, this fragmented funding approach belies the fact that diseases and poor services interact, often adversely. For example, in South Africa, where 300000 HIV-infected mothers give birth each year, AIDS is a critically important contributing cause to maternal death. The narrow vertical financing approaches of PEPFAR and the Global Fund, despite their stated health-systems commitments, are not well designed to deal with complex, multidimensional health problems faced by low-income countries.
The logic of the available evidence is that existing financing initiatives need to broaden their missions to include additional health goals-notably, maternal, newborn, and child health. This redrafting of purpose would match the gathering consensus around the continuum of care, strengthening primary health-care systems, integrated packages of care in communities, and now the possibility that relatively simple interventions-misoprostol and antibiotics-could save tens of thousands of mothers' lives.
PEPFAR and the Global Fund have transformed the landscape of global health. They have offered hope in place of despair, optimism instead of cynicism, and life over death. But they were designed for a time when the connections between health goals were incompletely understood and when prospects for solving the conundrum of maternal mortality seemed bleak. Neither of these assumptions is true today. It is time to place maternal health-as part of the continuum of care-at the centre of existing global health initiatives. It is the very least that women deserve.