Maternal Mortality & the MDGs Deborah Maine Professor, International Health Boston University, School of Public Health

MDG Goal: Improve maternal health Target: Reduce the MM Ratio by 3/4 by 2015 Indicators: l Maternal mortality ratio l Proportion of births attended by skilled health personnel

The MDG for MM Is it realistic ?

History MMRs Sri Lanka: Malaysia: 1950 > < 100

To reduce MM … l Need to understand the epidemiology of maternal mortality [MM] l A counterintuitive phenomenon l Many “obvious” approaches don’t work, e.g. risk screening, training TBAs

Maternal Mortality RegionMM RatioLifetime Risk 1 in … Africa83020 Asia33094 Latin America North America172,500 World40074

Causes of Direct Obstetric Deaths The “Big 5” l Hemorrhage l Infection l Hypertensive diseases l Obstructed labor l Unsafe induced abortion

The Way Programs Should Work Evidence Interventions Indicators Strategy

Interventions Indicators Strategy 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 l first clinics in UK (and US) l By 1930, 80% pregnant women in UK have prenatal care l 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, Bangladesh Maternal Age MM Ratio Relative Risk 3.91 # Births 50911,286 # Deaths 951

Example: United Kingdom Maternal Age MM Ratio37188 Relative Risk1 5.1 # Deaths242

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 ? l Expanding access to effective maternity care by midwives and doctors l 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 : l Parenteral antibiotics, oxytocics, anticonvulsants l Manual removal of placenta l Removal of retained products l Assisted vaginal delivery l Neonatal resuscitation (new) Should be at health centers

Signal Functions of Comprehensive EmOC: l All Basic EmOC functions l Blood transfusion l 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 Skilled Attendant Referral Risk Screening Social Mobilization Waiting Homes TBA Training Antenatal Care

Assumption EmOC is too expensive Community-based workers are more affordable

A cost-effectiveness exercise: unit cost Dollars $350 $10,000 $30,000

Cost (cont.) Suppose, per district, there are: l 100 MCHW s l 4 health centers l 1 district hospital

Estimated program cost (in $000s) Dollars

Estimated obstetric deaths prevented (%) 50 Percent 25 15

Estimated cost per death averted ($000) $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 Work Evidence Interventions Indicators Strategy But sometimes …

MDG Goal: Improve maternal health Target: Reduce the MM Ratio by 3/4 by 2015 Indicators: l Maternal mortality ratio l Proportion of births attended by skilled health personnel

Promoting SBAs What is the evidence base for this policy?

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.

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 > Health Facilities SBAs

Many Proposed Programs Health Facilities SBAs

In Reducing Maternal Deaths There are really only 3 issues: l COVERAGE OF SERVICES l QUALITY OF CARE l UTILIZATION OF SERVICES

The Road toMaternal Mortality Reduction: Shortcuts or Detours ?

Pseudo-Interventions l “Safe Birth Kits”: No evidence of effectiveness in reducing maternal deaths, but consume effort, attention and funds. l 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 l Need a strong evidence base l Training and equipment are never enough l Management systems are crucial l Even skilled personnel need support l Learn from expensive failures