Carine Ronsmans

Maternal mortality: who, when, where, and why

The risk of a woman dying as a result of pregnancy or childbirth during her lifetime is about one in six in the poorest parts of the world compared with about one in 30 000 in Northern Europe. Such a discrepancy poses a huge challenge to meeting the fifth Millennium Development Goal to reduce maternal mortality by 75% between 1990 and 2015. Some developed and transitional countries have managed to reduce their maternal mortality during the past 25 years. Few of these, however, began with the very high rates that are now estimated for the poorest countries-in which further progress is jeopardised by weak health systems, continuing high fertility, and poor availability of data. Maternal deaths are clustered around labour, delivery, and the immediate postpartum period, with obstetric haemorrhage being the main medical cause of death. Local variation can be important, with unsafe abortion carrying huge risk in some populations, and HIV/AIDS becoming a leading cause of death where HIV-related mortaliy rates are high. Inequalities in the risk of maternal death exist everywhere. Targeting of interventions to the most vulnerable--rural populations and poor people--is essential if substantial progress is to be achieved by 2015.

MATERNAL HEALTH IN POOR COUNTRIES: THE BROADER CONTEXT AND A CALL FOR ACTION

In this paper, we take a broad perspective on maternal health and place it in its wider context. We draw attention to the economic and social vulnerability of pregnant women, and stress the importance of concomitant broader strategies, including poverty reduction and womens empowerment. We also consider outcomes beyond mortality, in particular, near-misses and long-term sequelae, and the implications of the close association between the mother, the fetus, and the child. We make links to a range of global survival initiatives, particularly neonatal health, HIV, and malaria, and to reproductive health. Finally, after examining the political and financial context, we call for action. The need for strategic vision, financial resources, human resources, and information are discussed.

Huge poor-rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries

OBJECTIVE Progress towards the Millennium Development Goals for maternal health has been slow, and accelerated progress in scaling up professional delivery care is needed. This paper describes poor-rich inequalities in the use of maternity care and seeks to understand these inequalities through comparisons with other types of health care. METHODS Demographic and Health Survey (DHS) data from 45 developing countries were used to describe poor-rich inequalities by wealth quintiles in maternity care (professional delivery care and antenatal care), full childhood immunization coverage and medical treatment for diarrhoea and acute respiratory infections (ARI). FINDINGS Poor-rich inequalities in maternity care in general, and professional delivery care in particular, are much greater than those in immunization coverage or treatment for childhood illnesses. Public-sector inequalities make up a major part of the poor-rich inequalities in professional delivery attendance. Even delivery care provided by nurses and midwives favours the rich in most countries. Although poor-rich inequalities within both rural and urban areas are large, most births without professional delivery care occur among the rural poor. CONCLUSION Poor-rich inequalities in professional delivery care are much larger than those in the other forms of care. Reducing poor-rich inequalities in professional delivery care is essential to achieving the MDGs for maternal health. The greatest improvements in professional delivery care can be made by increasing coverage among the rural poor. Problems with availability, accessibility and affordability, as well as the nature of the services and demand factors, appear to contribute to the larger poor-rich inequalities in delivery care. A concerted effort of equity-oriented policy and research is needed to address the huge poor-rich inequalities in maternity care.

Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis

BACKGROUND Little is known about socioeconomic differences in access to life-saving obstetric surgery, yet access to a caesarean for women is essential to achieve low levels of maternal mortality. We examined population-based caesarean rates by socioeconomic groups in various developing countries. METHODS We used data from 42 Demographic and Health Surveys in sub-Saharan Africa, south and southeast Asia, and Latin America and the Caribbean. We report caesarean rates by wealth quintile and the absolute and relative difference between the richest and poorest quintiles. We also categorise the sample into richer and poorer halves and examine caesarean rates within rural areas. FINDINGS Caesarean rates were extremely low among the very poor: they were below 1% for the poorest 20% of the population in 20 countries and were below 1% for 80% of the population in six countries. Only in five countries did the very poor have caesarean rates exceeding 5%. At the other extreme are seven countries, mostly in Latin America, where caesareans are far in excess of the suggested maximum threshold of 15% for at least 40% of the population. INTERPRETATION In the poorest countries-mostly in sub-Saharan Africa-large segments of the population have almost no access to potentially life-saving caesareans, whereas in some mid-income countries more than half the population has rates in excess of medical need. These data deserve the immediate attention of policymakers at national and international levels.

How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys

BACKGROUND Achievement of global health goals will require assessment of progress not only nationally but also for population subgroups. We aimed to assess how the magnitude of socioeconomic inequalities in health changes in relation to different rates of national progress in coverage of interventions for the health of mothers and children. METHODS We assessed coverage in low-income and middle-income countries for which two Demographic Health Surveys or Multiple Indicator Cluster Surveys were available. We calculated changes in overall coverage of skilled birth attendants, measles vaccination, and a composite coverage index, and examined coverage of a newly introduced intervention, use of insecticide-treated bednets by children. We stratified coverage data according to asset-based wealth quintiles, and calculated relative and absolute indices of inequality. We adjusted correlation analyses for time between surveys and baseline coverage levels. FINDINGS We included 35 countries with surveys done an average of 9·1 years apart. Pro-rich inequalities were very prevalent. We noted increased coverage of skilled birth attendants, measles vaccination, and the composite index in most countries from the first to the second survey, while inequalities were reduced. Rapid changes in overall coverage were associated with improved equity. These findings were not due to a capping effect associated with limited scope for improvement in rich households. For use of insecticide-treated bednets, coverage was high for the richest households, but countries making rapid progress did almost as well in reaching the poorest groups. National increases in coverage were primarily driven by how rapidly coverage increased in the poorest quintiles. INTERPRETATION Equity should be accounted for when planning the scaling up of interventions and assessing national progress. FUNDING Bill & Melinda Gates Foundation; World Bank; Governments of Australia, Brazil, Canada, Norway, Sweden, and UK.

Maternal mortality and access to obstetric services in West Africa

Summary Objectives Process evaluation has become the mainstay of safe motherhood evaluation in developing countries, yet the extent to which indicators measuring access to obstetric services at the population level reflect levels of maternal mortality is uncertain. In this study we examine the association between population indicators of access to obstetric care and levels of maternal mortality in urban and rural West Africa.

Institutional delivery in rural India: the relative importance of accessibility and economic status

BackgroundSkilled attendance at delivery is an important indicator in monitoring progress towards Millennium Development Goal 5 to reduce the maternal mortality ratio by three quarters between 1990 and 2015. In addition to professional attention, it is important that mothers deliver their babies in an appropriate setting, where life saving equipment and hygienic conditions can also help reduce the risk of complications that may cause death or illness to mother and child. Over the past decade interest has grown in examining influences on care-seeking behavior and this study investigates the determinants of place of delivery in rural India, with a particular focus on assessing the relative importance of community access and economic status.MethodsA descriptive analysis of trends in place of delivery using data from two national representative sample surveys in 1992 and 1998 is followed by a two-level (child/mother and community) random-effects logistical regression model using the second survey to investigate the determinants.ResultsIn this investigation of institutional care seeking for child birth in rural India, economic status emerges as a more crucial determinant than access. Economic status is also the strongest influence on the choice between a private-for-profit or public facility amongst institutional births.ConclusionGreater availability of obstetric services will not alone solve the problem of low institutional delivery rates. This is particularly true for the use of private-for-profit institutions, in which the distance to services does not have a significant adjusted effect. In the light of these findings a focus on increasing demand for existing services seems the most rational action. In particular, financial constraints need to be addressed, and results support current trials of demand side financing in India.

Maternity wards or emergency obstetric rooms? Incidence of near-miss events in African hospitals

Background.  This study examines near‐miss obstetric events in African hospitals as to the frequency, nature, and ratio of near miss to death and considers whether these could become useful indicators for monitoring the performance of obstetric services in Africa.

Decline in maternal mortality in Matlab, Bangladesh: a cautionary tale

BACKGROUND A study in Matlab, Bangladesh, has provided evidence favouring a community-based maternity-care delivery system. 3 years of this programme coincided with a significant reduction in direct obstetric mortality compared with the 3 years before the programme. We have examined whether the effects of the programme are sustained over time. METHODS Using data from the continuing demographic survelliance system and from special investigations into the rates and causes of maternal mortality during 1976-93, we compared the trends in direct obstetric maternal mortality ratios in the Maternal and Child Health and Family Planning (MCH-FP) area (which has received extensive services in health and family planning since 1977) with those in the comparison area (with no such intensive health inputs). We divided the areas and time periods into discrete groups that best represented the effects of the introduction of the maternity-care programme. FINDINGS Direct obstetric mortality declined by 3% per year (rate ratio 0.97 per year [95% CI 0.95-0.99]); there was no difference between the MCH-FP and comparison areas (1.00 [0.96-1.05]). Direct obstetric mortality halved between 1976-86 and 1987-89 in the northern MCH-FP area, where the maternity-care programme was initiated in 1987 (0.50 [0.22-0.99]), but showed no change in the southern MCH-FP area, which had no such intervention at that time (1.07 [0.64-1.72]). After 1990, when the programme was expanded throughout the MCH-FP area, the southern part showed a downward (non-significant) trend in direct obstetric mortality (0.68 [0.35-1.32]). However, direct obstetric mortality also declined between 1987 and 1989 in the southern comparison area (0.48 [0.26-0.83]) in the absence of an intense maternity-care programme, and remained stable thereafter. In the northern comparison area, there was no such decline in direct obstetric mortality (0.78 [0.40-1.40]). INTERPRETATION Although the introduction of the maternity-care programme coincided with declining trends in direct obstetric mortality in the areas covered by the programme, a decline also occurred in one of the areas not receiving any such interventions. Caution is required in the interpretation of short-term trends in one indicator in studies designed without random allocation of interventions into treatment and control groups.

Determinants of reduction in maternal mortality in Matlab, Bangladesh: a 30-year cohort study.

BACKGROUND Research on the effectiveness of strategies to reduce maternal mortality is scarce. We aimed to assess the contribution of intervention strategies, such as skilled attendance at birth, to the recorded reduction in maternal mortality in Matlab, Bangladesh. We examined and compared trends in maternal mortality in two adjacent areas over 30 years, by separate analyses of causes of death, underlying sociodemographic determinants, and areas and time periods in which interventions differed. METHODS We analysed survey data that was routinely collected between 1976 and 2005 for about 200 000 inhabitants of Matlab, in Bangladesh, in adjacent areas served by either the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) or by the government. We used logistic regression to assess time trends in maternal mortality. We separately analysed deaths due to direct obstetric causes, abortion-related causes, and other causes. FINDINGS Maternal mortality fell by 68% in the ICDDR,B service area and by 54% in the government service area over 30 years. Maternal mortality remained stable between 1976 and 1989 (crude annual OR 1.00 [0.98-1.01]) but decreased substantially after 1989 (OR 0.95 [0.93-0.97]). The speed of decline was faster after the skilled-attendance strategy was introduced in the ICDDR,B service area in 1990 (p=0.09). Abortion-related mortality fell sharply from 1990 onwards (OR 0.91 [0.86-0.95]). Educational differentials for mortality were substantial; the OR for more than 8 years of schooling compared with no schooling was 0.30 (0.21-0.44) for maternal mortality and 0.09 (0.02-0.37) for abortion mortality. INTERPRETATION The fall in maternal mortality over 30 years occurred despite a low uptake of skilled attendance at birth. Part of the decline was due to a fall in abortion-related deaths and better access to emergency obstetric care; midwives might also have contributed by facilitating access to emergency care. Investment in midwives, emergency obstetric care, and safe pregnancy termination by manual vacuum aspiration have clearly been important. However, additional policies, such as those that bring about expansion of female education, better financial access for the poor, and poverty reduction, are essential to sustain the successes achieved to date.