Feature Story

14 September 2010

Stories and Strategies Behind Recent Reductions in Maternal Mortality

It took 30-year-old Zemzem 20 hours to get from her rural village in Ethiopia to the nearest hospital for the delivery of her fifth child. By the time she arrived, her uterus had ruptured. But because health workers had the capacity to operate quickly, as well as medicine to staunch the bleeding, and antibiotics and equipment for a blood transfusion, they managed to save the life of her and her baby. And because Ethiopia is scaling up access to contraception, women like Zemzem can avoid facing a risking pregnancy too soon.

When 21-year-old Manakala Darlami of Nepal began bleeding profusely after the birth of her fourth child, members of the village safe motherhood committee were called to help. Although it took three hours to get her to the hospital, and blood donations to save her, Manakala pulled through.

In many countries of Latin America and in Viet Nam, women who have been reluctant to seek trained obstetrical care because of the insensitivity they once encountered now have access to midwives and health workers who come from their own indigenous communities or are trained to respect their cultural traditions surrounding childbearing.

Across the world, countries are implementing a wide variety of strategies to save women’s lives. In many places, people who once believed that death was an inevitable risk of childbearing are now realizing that no woman should die giving life.

Validation of key strategies for reducing maternal death

The recent drop in maternal mortality rates – by about a third worldwide – seems to validate what many health experts have been saying for years: that the strategies for reducing maternal deaths are straightforward and that the missing ingredient has been commitment and resources. The MDG 5 target for reducing maternal mortality by 75 per cent by 2015 (compared to 1990) seems to have galvanized countries, communities, civil society and donors to build on successful strategies.

Nevertheless, the 2.4 annual rate of decline in maternal death is less than half of what is needed to meet the MDG indicator. Moreover, the averages mask wide, and in some cases, widening disparities. The poorest, least educated and most marginalized women continue to die in childbirth at unacceptable rates, as do women living in rural areas.

Working Towards Maternal Health: Why Data Matters

Complacency is not an option

“We welcome the new estimates on maternal mortality and are thrilled by the decline,” said Thoraya Ahmed Obaid, Executive Director of UNFPA, the United Nations Population Fund. “But we can’t become complacent. The new figures show that the interventions work. But we need to do more. There are still 800 women who die every day in pregnancy or childbirth, and more than 200 million women with an unmet need for family planning.”

Strategies that have shown success include access to contraception to prevent unintended pregnancies (each of which multiplies the risk of maternal death), skilled care before and during childbirth and emergency obstetric interventions when complications arise. Having the needed reproductive health supplies and equipment available is essential as well. And, mobilizing communities and health systems to reduce the three delays (in the decision to seek help, in the time it takes to reach help, and in the waiting time at health facilities) can play a large role in saving women’s lives.

Government commitment is key

In Rwanda the maternal mortality rate has declined by more than half since 1990, in spite of the 1994 genocide that destroyed the country’s infrastructure and social fabric. The percentage of women giving birth with a skilled attendant has doubled to 52 percent , and about twice as many women are getting at least four prenatal checkups and giving births in health centres or hospitals. Contraceptive prevalence has jumped from 21 to 36 per cent. The impressive improvement in statistics shows what is possible when a government is committed to the cause.

Rwanda’s community-based health insurance makes care affordable for many women who otherwise would have gone through pregnancy and childbirth largely on their own. A number of other policies, strategies and laws have been adopted to accelerate sustainable development, and improving women’s lives are at the heart of many of these initiatives. More health professionals are being trained in emergency obstetric care and in rural areas, and community health workers are being trained to monitor pregnant women. Maternal death audits are now done at hospitals and health centers in order to identify why women have died and what measures need to be taken to prevent similar deaths. Overall, the health system has been decentralized and a strict system of accountability has been put in place at all levels.

Success plays out in different ways

Similar strategies, employed in different ways depending on country circumstances, are making a difference in countries as diverse as Cape Verdi, Ethiopia, Bolivia, India and Egypt .

In Cape Verde where maternal deaths have declined by half since 1990, over three-quarters of births are attended by skilled health personnel and the same percentage of birth take place in health facilities. This is about twice the average for the rest of sub-Saharan Africa, which accounts for 75 per cent of maternal deaths worldwide.

In Egypt maternal deaths have been reduced by over 60 per cent, while the fertility rate has declined significantly – from 4.6 to just under 3. Improvements in access to maternal health services are improving the lives of women in rural as well as urban areas. Nationwide, 8 in 10 births now occur with the help of a skilled attendant, a doubling in coverage since the mid 1990s. Among rural women, coverage increased by a striking 10 per cent per year.

Scaling up for success

India has a population of nearly a billion people, so its improvements in maternal mortality – from 570 deaths per 100,000 live births in 1990 to 230 in 2008 make a big impact on the worldwide figures. Advocacy and lobbying by civil society encouraged the government to prioritize maternal health and institutionalize best practices so that successful programmes are now reaching larger numbers of women. The use of ‘conditional cash transfers’ to encourage women to seek professional care and institutional deliveries are paying off as well. In India, like most countries, wide disparities in maternal health are seen from state to state, and among different social and economic groups within states.

In Bolivia, the maternal mortality rate is now less than half of what it was in 1990, making it one of countries with the highest decline. One reason is that 19 per cent of deliveries are by Caesarean section. This is an indication that the country’s attention to providing adequate emergency obstetric care in the country is saving women’s lives.

Progress eludes many countries

Though the maternal mortality rate in sub-Saharan Africa as a whole has decreased by 26 per cent, that level of progress has eluded a number of countries, including Chad, Guinea-Bissau, Liberia and Sierra Leone, where maternal deaths are staggeringly high: from 970 to 1200 per 100,000 live births. Things may be changing, however. Sierra Leone’s government has recently undertaken a major push to reduce maternal mortality, by offering free health care for pregnant and lactating women and their children under five. The African Union, as well as some 20 other countries have launched CARMMA, the Campaign on Accelerated Reduction of Maternal Mortality in Africa, and the continent’s influential first ladies have rallied around the importance of saving women’s lives.

Not surprisingly, progress has also stalled, or reversed, in countries affected by conflict, such as Afghanistan,  the Democratic Republic of Congo and Sudan.