Marge Koblinsky

Going to scale with professional skilled care.

Because most women prefer professionally provided maternity care when they have access to it, and since the needed clinical interventions are well known, we discuss in their paper what is needed to move forward from apparent global stagnation in provision and use of maternal health care where maternal mortality is high. The main obstacles to the expansion of care are the dire scarcity of skilled providers and health-system infrastructure, substandard quality of care, and womens reluctance to use maternity care where there are high costs and poorly attuned services. To increase the supply of professional skilled birthing care, strategic decisions must be made in three areas: training, deployment, and retention of health workers. Based on results from simulations, teams of midwives and midwife assistants working in facilities could increase coverage of maternity care by up to 40% by 2015. Teams of providers are the efficient option, creating the possibility of scaling up as much as 10 times more quickly than would be the case with deployment of solo health workers in home deliveries with dedicated or multipurpose workers.

Inequity in maternal health-care services: evidence from home-based skilled-birth-attendant programmes in Bangladesh.

OBJECTIVE To explore use-inequity in maternal health-care services in home-based skilled-birth-attendant (SBA) programme areas in Bangladesh. METHODS Data from a community survey, conducted from February to May 2006, were analysed to examine inequities in use of SBAs, caesarean sections for deliveries and postnatal care services according to key socioeconomic factors. FINDINGS Of 2164 deliveries, 35% had an SBA, 22.8% were in health facilities and 10.8% were by caesarean section. Rates of uptake of antenatal and postnatal care were 93% and 28%, respectively. There were substantial use-inequities in maternal health by asset quintiles, distance, and area of residence, and education of both the woman and her husband. However, not all inequities were the same. After adjusting for other determinants, the differences in the use of maternal health-care services for poor and rich people remained substantial [adjusted odds ratio (OR) 2.51 (95% confidence interval, CI: 1.68-3.76) for skilled attendance; OR 2.58 (95% CI: 1.28-5.19) for use of caesarean sections and OR 1.53 (95% CI: 1.05-2.25) for use of postnatal care services]. Complications during pregnancy influenced use of SBAs, caesarean-section delivery and postnatal care services. The number of antenatal care visits was a significant predictor for use of SBAs and postnatal care, but not for caesarean sections. CONCLUSION Use of maternity care services was higher in the study areas than national averages, but a tremendous use-inequity persists. Interventions to overcome financial barriers are recommended to address inequity in maternal health. A greater focus is needed on the implementation and evaluation of maternal-health interventions for poor people.

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.

Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality.

This paper complements the other papers in the Lancet Series on midwifery by documenting the experience of low-income and middle-income countries that deployed midwives as one of the core constituents of their strategy to improve maternal and newborn health. It examines the constellation of various diverse health-system strengthening interventions deployed by Burkina Faso, Cambodia, Indonesia, and Morocco, among which the scaling up of the pre-service education of midwives was only one element. Efforts in health system strengthening in these countries have been characterised by: expansion of the network of health facilities with increased uptake of facility birthing, scaling up of the production of midwives, reduction of financial barriers, and late attention for improving the quality of care. Overmedicalisation and respectful woman-centred care have received little or no attention.

Effect of parent's death on child survival in rural Bangladesh: a cohort study

BACKGROUND The effect of a parents death on the survival of the children has been assessed in only a few studies. We therefore investigated the effect of the death of the mother or father on the survival of the child up to age 10 years in rural Bangladesh. METHODS We used data from population surveillance during 1982-2005 in Matlab, Bangladesh. We used Kaplan-Meier and Poisson regression analyses to compute the cumulative probabilities of survival and rates of age-specific death up to age 10 years, according to the survival status of the mother or father during that period. FINDINGS There were 144 861 livebirths, and 14 868 children died by 10 years of age. The cumulative probability of survival to age 10 years was 24% in children whose mothers died (n=1385) before their tenth birthday, compared with 89% in those whose mothers remained alive (n=143 473). The greatest effect was noted in children aged 2-5 months whose mothers had died (rate ratio 25.05, 95% CI 18.57-33.81). The effect of the fathers death (n=2691) on cumulative probability of survival of the child up to 10 years of age was negligible. Age-specific death rates did not differ in children whose fathers died compared with children whose fathers were alive. INTERPRETATION The devastating effects of the mothers death on the survival of the child were most probably due to the abrupt cessation of breastfeeding, but the persistence of the effects up to 10 years of age suggest that the absence of maternal care might be a crucial factor. FUNDING US Agency for International Development, UK Department for International Development, Research Program Consortium, and National Institutes of Health Fogarty International Center.

Beyond maternal mortality — magnitude, interrelationship and consequences of women's health, pregnancy-related complications and nutritional status on pregnancy outcomes

The magnitude of maternal morality in developing countries and its disparity with similar statistics from the developed world has touched a responsive chord among policy makers and health services program officials. What is not well appreciated, however, is that maternal mortality is only the tip of the iceberg — for every one maternal death, acute obstetrical complications cause suffering in nearly 100 women, 250 women contract a sexually transmitted disease, and 1000 women suffer stunting and/or anemia. All of these problems impact on the pregnancy outcome, both for the woman as well as for the newborn. Through a review of the literature, the magnitude, interrelationships and consequences of these various problems are described. The woman and the newborn are a dyad, a unit; what affects the woman typically affects the fetus and is manifest in the newborn. Safe motherhood programs need to pay attention to both, realizing that interventions aimed at the woman can benefit the next generation.

An integrated village maternity service to improve referral patterns in a rural area in West-Java

The Regionalization of Perinatal Care, an intervention study carried out in Tanjungsari, a subdistrict in rural West Java, aimed to develop a comprehensive maternal health program to improve maternal and perinatal health outcomes. The main inputs included training at all levels of the health care system (informal and formal) and the establishment of birthing homes in villages to make services more accessible. Special attention was given to referral, transportation, communication and appropriate case management, A social marketing program was conducted to inform people of the accessible birthing homes for clean delivery, located near the women, and with better transportation and communications to referral facilities should complications arise. The study design was longitudinal, following all pregnant women from early pregnancy until 42 days postpartum in an intervention and a comparison area. The population was ± 90 000 in the intervention area and 40 000 in the comparison area. Inclusion criteria were all mother and infant units delivered between June 1st, 1992 and May 31st, 1993.

Causes of Maternal Mortality Decline in Matlab, Bangladesh

Bangladesh is distinct among developing countries in achieving a low maternal mortality ratio (MMR) of 322 per 100,000 livebirths despite the very low use of skilled care at delivery (13% nationally). This variation has also been observed in Matlab, a rural area in Bangladesh, where longitudinal data on maternal mortality are available since the mid-1970s. The current study investigated the possible causes of the maternal mortality decline in Matlab. The study analyzed 769 maternal deaths and 215,779 pregnancy records from the Health and Demographic Surveillance System (HDSS) and other sources of safe motherhood data in the ICDDR,B and government service areas in Matlab during 1976-2005. The major interventions that took place in both the areas since the early 1980s were the family-planning programme plus safe menstrual regulation services and safe motherhood interventions (midwives for normal delivery in the ICDDR,B service area from the late 1980s and equal access to comprehensive emergency obstetric care [EmOC] in public facilities for women from both the areas). National programmes for social development and empowerment of women through education and microcredit programmes were implemented in both the areas. The quantitative findings were supplemented by a qualitative study by interviewing local community care providers for their change in practices for maternal healthcare over time. After the introduction of the safe motherhood programme, reduction in maternal mortality was higher in the ICDDR,B service area (68.6%) than in the government service area (50.4%) during 1986-1989 and 2001-2005. Reduction in the number of maternal deaths due to the fertility decline was higher in the government service area (30%) than in the ICDDR,B service area (23%) during 1979-2005. In each area, there has been substantial reduction in abortion-related mortality—86.7% and 78.3%—in the ICDDR,B and government service areas respectively. Education of women was a strong predictor of the maternal mortality decline in both the areas. Possible explanations for the maternal mortality decline in Matlab are: better access to comprehensive EmOC services, reduction in the total fertility rate, and improved education of women. To achieve the Millenium Development Goal 5 targets, policies that bring further improved comprehensive EmOC, strengthened family-planning services, and expanded education of females are essential.

Evaluation of a comprehensive home‐based midwifery programme in South Kalimantan, Indonesia

We report the findings of an evaluation of a programme in three districts in South Kalimantan, Indonesia, which consisted of the training, deployment and supervision of a large number of professional midwives in villages, an information, education and communication (IEC) strategy to increase use of village midwives for birth, and a district‐based maternal and perinatal audit (MPA). Before the programme, the midwives had limited ability to manage obstetric complications, and 90% of births took place at home. Only 37% were attended by a skilled attendant. By 1998–99, 510 midwives were posted in the districts and skilled attendance at delivery had increased to 59%. Through in‐service training, continuous supervision and participation in the audit system midwives also gained confidence and skills in the management of obstetric complications. Despite this, the proportion admitted to hospital for a caesarean section declined from 1.7 to 1.4% and the proportion admitted to hospital with a complication requiring a life‐saving intervention declined from 1.1% to 0.7%. The strategy of a midwife in every village has dramatically increased skilled birth attendance, but does not yet provide specialized obstetric care for all women needing it. The high cost of emergency obstetric interventions may well be the most important obstacle to the use of hospital care.

Questioning the indicators of need for obstetric care

The difficulties in measuring maternal mortality have led to a shift in emphasis from indicators of health to indicators of use of health care services. Furthermore, the recognition that some women need specialist obstetric care to prevent maternal death has led to the search for indicators measuring the met need for obstetric care. Although intuitively appealing, the conceptualization and definition of the need for obstetric care is far from straightforward, and there is relatively little experience so far in the use and interpretation of indicators of service use or need for obstetric care. In this paper we review indicators of service use and need for obstetric care, and briefly discuss data collection issues.