Isabella Danel

Towards elimination of maternal deaths: maternal deaths surveillance and response

Current methods for estimating maternal mortality lack precision, and are not suitable for monitoring progress in the short run. In addition, national maternal mortality ratios (MMRs) alone do not provide useful information on where the greatest burden of mortality is located, who is concerned, what are the causes, and more importantly what sub-national variations occur. This paper discusses a maternal death surveillance and response (MDSR) system. MDSR systems are not yet established in most countries and have potential added value for policy making and accountability and can build on existing efforts to conduct maternal death reviews, verbal autopsies and confidential enquiries. Accountability at national and sub-national levels cannot rely on global, regional and national retrospective estimates periodically generated from academia or United Nations organizations but on routine counting, investigation, sub national data analysis, long term investments in vital registration and national health information systems. Establishing effective maternal death surveillance and response will help achieve MDG 5, improve quality of maternity care and eliminate maternal mortality (MMR ≤ 30 per 100,000 by 2030).

Maternal death surveillance and response

Of the eight United Nations Millennium Development Goals, the goal of reducing maternal mortality is the one that remains the furthest from reaching its targets.1–3 The inability to reliably measure levels and trends contributes to a lack of accountability and, in turn, to lack of progress. A maternal death surveillance and response system that includes maternal death identification, reporting, review and response can provide the essential information to stimulate and guide actions to prevent future maternal deaths and improve the measurement of maternal mortality. The current convergence of factors including political will, technical innovations and financial resources provides an ideal opportunity to make such systems a reality for low-income countries. In September 2010, the Secretary-General of the United Nations launched the Global Strategy for Women’s and Children’s Health, focusing on the 49 lowest-income countries where maternal and child mortality rates are highest.4 The Commission on Information and Accountability for Womens and Childrens Health, established in the wake of that report, stressed the lack of reliable data to monitor progress and also flagged issues concerning the quality of care. The Commissions ten recommendations, announced in September 2011, focused on strengthening country and global accountability.5 The Commission urged countries to improve their health information systems, take significant steps to develop civil registration and vital statistics systems, and introduce innovative methods to count all maternal deaths and to review and better monitor progress. Maternal mortality measurement, including numbers of deaths, their causes and circumstances, remains a challenge in low-income countries.6 Only two of the 49 lowest-income countries have functional, civil registration and vital statistics systems, the preferred source of data for counting deaths.7 In the absence of such systems, alternative methods used to collect retrospective data on maternal mortality include census (recent deaths in the household), household surveys (sibling survival history) and special studies. The uncertainty of statistics derived using these methods tends to be very large. Furthermore, the data refer to the past and are generally not available at the sub-national level, making them unsuitable for proactive response, planning or resource allocation. New and exciting opportunities for using information and communication technologies have great potential to help countries improve birth and death registration systems. Projects across sub-Saharan Africa and Asia are increasingly demonstrating the feasibility of using mobile devices to track and support maternal care in facility and community settings, often starting with the registration of pregnancies. A national maternal death surveillance and response system should draw upon two main sources of information. Within the health system, facilities should be required to report all deaths of women during pregnancy, delivery and the postpartum period. All such deaths should be routinely reviewed or audited as an integral aspect of health-care quality improvement. Reporting systems, preferably internet-based, should be linked to review and action. At the community level, local networks of informants from the health, administrative or traditional authorities should report maternal deaths. They should primarily use cell phones to immediately notify deaths to district authorities who then report up the chain to the national level. There the data received from both health facilities and the community are reviewed, compiled and analysed. Several countries have made maternal death a notifiable event and this can, if enforced, work together with technology to enhance maternal death surveillance. This approach not only takes advantage of innovations in statistics reporting, but simultaneously improves response mechanisms to avoid future deaths. Over the past years, many low-income countries have introduced action-oriented review mechanisms, described under various names including maternal death enquiry, review or audit.8–10 These require analysis of the circumstances of each death, identification of avoidable factors and action to improve care at all levels of the health system, from home to hospital. Much of the responsibility for follow-up actions lies with district and local health authorities. At the same time, active civil society engagement is needed to ensure that the circumstances surrounding each death are fully elucidated and that there are comprehensive and feasible recommendations for follow-up action. This linking of mortality surveillance with remedial action is the centre-piece of an accountability framework. Maternal death surveillance and response systems have the potential to deliver real-time, frequent monitoring of maternal mortality levels, trends and causes, provided investments are made to assess the completeness of reporting and data accuracy as part of the system. If successful, such systems would be a major step forward in the measurement of maternal mortality. Moreover, they would serve as the basis for a longer-term advancement, namely, strengthening the civil registration and vital statistics system. The Commission on Information and Accountability for Women’s and Children’s Health has created renewed momentum for building action-oriented maternal mortality surveillance systems. Through innovation and the concerted efforts of all partners, maternal mortality can at last be monitored in real time and prompt immediate actions to improve maternal health. There has never been a better opportunity.

Female Genital Mutilation/Cutting in the United States: Updated Estimates of Women and Girls at Risk, 2012

Objectives. In 1996, the U.S. Congress passed legislation making female genital mutilation/cutting (FGM/C) illegal in the United States. CDC published the first estimates of the number of women and girls at risk for FGM/C in 1997. Since 2012, various constituencies have again raised concerns about the practice in the United States. We updated an earlier estimate of the number of women and girls in the United States who were at risk for FGM/C or its consequences. Methods. We estimated the number of women and girls who were at risk for undergoing FGM/C or its consequences in 2012 by applying country-specific prevalence of FGM/C to the estimated number of women and girls living in the United States who were born in that country or who lived with a parent born in that country. Results. Approximately 513,000 women and girls in the United States were at risk for FGM/C or its consequences in 2012, which was more than three times higher than the earlier estimate, based on 1990 data. The increase in the number of women and girls younger than 18 years of age at risk for FGM/C was more than four times that of previous estimates. Conclusion. The estimated increase was wholly a result of rapid growth in the number of immigrants from FGM/C-practicing countries living in the United States and not from increases in FGM/C prevalence in those countries. Scientifically valid information regarding whether women or their daughters have actually undergone FGM/C and related information that can contribute to efforts to prevent the practice in the United States and provide needed health services to women who have undergone FGM/C are needed.

HIV and maternal mortality

The majority of the 17 million women globally that are estimated to be infected with HIV live in Sub‐Saharan Africa. Worldwide, HIV‐related causes contributed to 19 000–56 000 maternal deaths in 2011 (6%–20% of maternal deaths). HIV‐infected pregnant women have two to 10 times the risk of dying during pregnancy and the postpartum period compared with uninfected pregnant women. Many of these deaths can be prevented with the implementation of high‐quality obstetric care, prevention and treatment of common co‐infections, and treatment of HIV with ART. The paper summarizes what is known about HIV disease progression in pregnancy, specific causes of HIV‐related maternal deaths, and the potential impact of treatment with antiretroviral therapy on maternal mortality. Recommendations are proposed for improving maternal health and decreasing maternal mortality among HIV‐infected women based on existing evidence.

Eliminating Preventable HIV-Related Maternal Mortality in Sub-Saharan Africa: What Do We Need to Know?

Introduction:HIV makes a significant contribution to maternal mortality, and women living in sub-Saharan Africa are most affected. International commitments to eliminate preventable maternal mortality and reduce HIV-related deaths among pregnant and postpartum women by 50% will not be achieved without a better understanding of the links between HIV and poor maternal health outcomes and improved health services for the care of women living with HIV (WLWH) during pregnancy, childbirth, and postpartum. Methods:This article summarizes priorities for research and evaluation identified through consultation with 30 international researchers and policymakers with experience in maternal health and HIV in sub-Saharan Africa and a review of the published literature. Results:Priorities for improving the evidence about effective interventions to reduce maternal mortality and improve maternal health among WLWH include better quality data about causes of maternal death among WLWH, enhanced and harmonized program monitoring, and research and evaluation that contributes to improving: (1) clinical management of pregnant and postpartum WLWH, including assessment of the impact of expanded antiretroviral therapy on maternal mortality and morbidity, (2) integrated service delivery models, and (3) interventions to create an enabling social environment for women to begin and remain in care. Conclusions:As the global community evaluates progress and prepares for new maternal mortality and HIV targets, addressing the needs of WLWH must be a priority now and after 2015. Research and evaluation on maternal health and HIV can increase collaboration on these 2 global priorities, strengthen political constituencies and communities of practice, and accelerate progress toward achievement of goals in both areas.

Surveillance of assisted reproductive technology in the United States. An update.

The Centers for Disease Control and Prevention published the first Assisted Reproductive Technology (ART) Pregnancy Success Rate Report in 1997. This article presents a description of the law that initiated the public report, a description of the surveillance system used to accumulate data for the report, and some of the results from ART cycles initiated in 1995.

Rapid reduction of maternal mortality in Uganda and Zambia through the saving mothers, giving life initiative: results of year 1 evaluation

BackgroundAchieving maternal mortality reduction as a development goal remains a major challenge in most low-resource countries. Saving Mothers, Giving Life (SMGL) is a multi-partner initiative designed to reduce maternal mortality rapidly in high mortality settings through community and facility evidence-based interventions and district-wide health systems strengthening that could reduce delays to appropriate obstetric care.MethodsAn evaluation employing multiple studies and data collection methods was used to compare baseline maternal outcomes to those during Year 1 in SMGL pilot districts in Uganda and Zambia. Studies include health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and population-based investigation of community maternal deaths. Population-based evaluation used standard approaches and comparable indicators to measure outcome and impact, and to allow comparison of the SMGL implementation in unique country contexts.ResultsThe evaluation found a 30% reduction in the population-based maternal mortality ratio (MMR) in Uganda during Year 1, from 452 to 316 per 100,000 live births. The MMR in health facilities declined by 35% in each country (from 534 to 345 in Uganda and from 310 to 202 in Zambia). The institutional delivery rate increased by 62% in Uganda and 35% in Zambia. The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 25 in Uganda and from 7 to 11 in Zambia. Partial EmONC care became available in many more low and mid-level facilities. Cesarean section rates for all births increased by 23% in Uganda and 15% in Zambia. The proportion of women with childbirth complications delivered in EmONC facilities rose by 25% in Uganda and 23% in Zambia. Facility case fatality rates fell from 2.6 to 2.0% in Uganda and 3.1 to 2.0% in Zambia.ConclusionsMaternal mortality ratios fell significantly in one year in Uganda and Zambia following the introduction of the SMGL model. This model employed a comprehensive district system strengthening approach. The lessons learned from SMGL can inform policymakers and program managers in other low and middle income settings where similar approaches could be utilized to rapidly reduce preventable maternal deaths.

Perfil situacional y estrategias de intervención en la región mesoamericana en el área de salud materna, reproductiva y neonatal

Presentar los principales resultados del diagnostico situacional y plan regional de intervenciones en salud materna, reproductiva y neonatal elaborado como parte de los trabajos del Sistema Mesoamericano de Salud por el grupo de salud materna, reproductiva y neonatal (SMRN) en 2010. Se conformo un grupo de expertos y de representantes de los paises de la region (que incluye Centroamerica y nueve estados del sur de Mexico). Se hizo una revision documental para conformar un diagnostico situacional, una revision de practicas efectivas y se conformo un plan regional de accion. El diagnostico situacional indica que las tasas de mortalidad materna y neonatal se mantienen inaceptablemente altas en la region. Se propuso como meta regional reducir la mortalidad materna y neonatal de acuerdo a los Objetivos de Desarrollo del Milenio. Se conformo un plan regional que identifica intervenciones especificas en SMRN con enfasis en la atencion adecuada a las emergencias obstetricas y neonatales, atencion calificada al nacimiento, y en planificacion familiar. Se sugiere asimismo un plan de implementacion a cinco anos y una estrategia de evaluacion y de capacitacion. El plan regional en SMRN puede tener exito siempre y cuando los aspectos de implementacion sean atendidos debidamente.