Oona M. R. Campbell

Strategies for reducing maternal mortality: getting on with what works

The concept of knowing what works in terms of reducing maternal mortality is complicated by a huge diversity of country contexts and of determinants of maternal health. Here we aim to show that, despite this complexity, only a few strategic choices need to be made to reduce maternal mortality. We begin by presenting the logic that informs our strategic choices. This logic suggests that implementation of an effective intrapartum-care strategy is an overwhelming priority. We also discuss the alternative configurations of such a strategy and, using the best available evidence, prioritise one strategy based on delivery in primary-level institutions (health centres), backed up by access to referral-level facilities. We then go on to discuss strategies that complement intrapartum care. We conclude by discussing the inexplicable hesitation in decision-making after nearly 20 years of safe motherhood programming: if the fifth Millennium Development Goal is to be achieved, then what needs to be prioritised is obvious. Further delays in getting on with what works begs questions about the commitment of decision-makers to this goal.

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.

The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015

Bringing together analysis across different sectors, we review the implementation and achievements of the MDGs to date to identify cross cutting strengths and weaknesses as a basis for considering how they might be developed or replaced after 2015. Working from this and a definition of development as a dynamic process involving sustainable and equitable access to improved wellbeing, five interwoven guiding principles are proposed for a post 2015 development project: holism, equity, sustainability, ownership, and global obligation. These principles and their possible implications in application are expanded and explored. The paper concludes with an illustrative discussion of how these principles might be applied in the health sector.

The Influence of Distance and Level of Care on Delivery Place in Rural Zambia: A Study of Linked National Data in a Geographic Information System

Using linked national data in a geographic information system system, Sabine Gabrysch and colleagues investigate the effects of distance to care and level of care on womens use of health facilities for delivery in rural Zambia.

High ANC coverage and low skilled attendance in a rural Tanzanian district: a case for implementing a birth plan intervention

BackgroundIn Tanzania, more than 90% of all pregnant women attend antenatal care at least once and approximately 62% four times or more, yet less than five in ten receive skilled delivery care at available health units. We conducted a qualitative study in Ngorongoro district, Northern Tanzania, in order to gain an understanding of the health systems and socio-cultural factors underlying this divergent pattern of high use of antenatal services and low use of skilled delivery care. Specifically, the study examined beliefs and behaviors related to antenatal, labor, delivery and postnatal care among the Maasai and Watemi ethnic groups. The perspectives of health care providers and traditional birth attendants on childbirth and the factors determining where women deliver were also investigated.MethodsTwelve key informant interviews and fifteen focus group discussions were held with Maasai and Watemi women, traditional birth attendants, health care providers, and community members. Principles of the grounded theory approach were used to elicit and assess the various perspectives of each group of participants interviewed.ResultsThe Maasai and Watemi womens preferences for a home birth and lack of planning for delivery are reinforced by the failure of health care providers to consistently communicate the importance of skilled delivery and immediate post-partum care for all women during routine antenatal visits. Husbands typically serve as gatekeepers of womens reproductive health in the two groups - including decisions about where they will deliver- yet they are rarely encouraged to attend antenatal sessions. While husbands are encouraged to participate in programs to prevent maternal-to-child transmission of HIV, messages about the importance of skilled delivery care for all women are not given emphasis.ConclusionsIncreasing coverage of skilled delivery care and achieving the full implementation of Tanzanias Focused Antenatal Care Package in Ngorongoro depends upon improved training and monitoring of health care providers, and greater family participation in antenatal care visits.

Epidemiology of menstrual disorders in developing countries: a systematic review

In developing countries priority setting in the health sector traditionally focuses on the principal causes of mortality. More recently the Global Burden of Disease approach incorporates assessment of morbidity and quality of life in identifying priorities. Yet although investigations in various developing countries reveal that women are concerned by menstrual disorders little attention is paid to understanding or ameliorating women’s menstrual complaints. Menstrual dysfunction like other aspects of sexual and reproductive health is not included in the Global Burden of Disease estimates and even as reproductive health programs expand their focus to address gynaecologic morbidity the utility of evaluating and treating menstrual problems is not generally considered. Available data from developing countries on the frequency of menstrual disorders and their impact on women’s health status quality of life and social integration suggest that evaluation and treatment of menstrual complaints should be given a higher priority in primary care programs. This article reviews the literature on the prevalence of menstrual morbidity in developing countries and suggests a strategy for improving the quality of services provided to women with menstrual complaints. (authors)

Reducing maternal mortality in the developing world: sector-wide approaches may be the key.

Reducing “the rate of maternal mortality by 75% by 2015” is one of the development targets that has been endorsed at numerous international meetings.1 This target was selected because maternal ill health is the largest contributor to the disease burden affecting women in developing countries; because the lifetime risk of maternal death is much greater in the poorest countries than in the richest (1 in 12 for women in east Africa compared with 1 in 4000 in northern Europe); and because interventions are cost effective (costing £2 (

Women's experiences of maternity care : satisfaction or passivity?

3) per woman and £153 (

Birth Intervals and Childhood Mortality in Rural Bangladesh

230) per death averted).2–5 #### Summary points Reducing maternal mortality in developing countries is an international priority Preventing maternal deaths requires a functioning health system Sector-wide approaches allow donors to support improvements in health systems Sector-wide approaches offer the opportunity to make a sustainable impact on maternal mortality Improvements in maternal health can be used to measure the performance of sector-wide approaches The technical interventions needed to prevent maternal deaths are well understood.6 Traditional maternal and child health interventions, such as providing antenatal care and training traditional birth attendants, have failed. 2 7 The availability, accessibility, use, and quality of essential obstetric care for life threatening conditions, including complications after abortion, need to be improved (box). 2 6 7 What is less clear is how an environment can be created to enable interventions to be made in settings with few resources.8 #### Causes of maternal deaths Severe bleeding 25% Indirect causes including anaemia, malaria, 20% heart disease Infection 15% Unsafe abortion 13% Eclampsia 12% Obstructed labour 8% Other direct causes including ectopic pregnancy, 8% embolism, or complications of anaesthesia Creating a functioning health system is the most obvious means of providing this type of environment. Most of the resources needed to improve essential obstetric care exist as integral parts of …