dcpp-mm sheet_v2.indd - disease control priorities project
TRANSCRIPT
Two of the eight Millennium Development Goals (MDGs)
embraced by UN members in 2000 target the health of
mothers and children, testifying to the vast inequities in
maternal and child health within and between countries.
In 2001, maternal and perinatal conditions represented
the single largest contributor to the global burden of
disease, at nearly 6 percent of total Disability Adjusted Life
Years (DALYs).* About 500,000 women die as a result of
pregnancy or childbirth, nearly all in developing countries.
Maternal and newborn mortality are regarded as sensitive
indicators of the entire health system, and can be used to
monitor general health gains. However, these deaths also
represent the most serious challenges to achieving the MDGs,
particularly in South Asia and sub-Saharan Africa.
Experts agree that nearly all maternal deaths could be
prevented with proper prenatal and postnatal care, along
with skilled attendance at childbirth and the availability
of emergency care for serious complications. The clinical
interventions needed to avert much of the disease burden
from maternal deaths require a reasonably well-functioning
health system.
This fact sheet focuses on causes and management of
conditions that arise during pregnancy and delivery resulting
in the death of the mother. Maternal health is intricately
linked with newborn health, which is discussed in detail in
the “Newborn Health” fact sheet.
Causes of Maternal Deaths
Maternal conditions encompass events occurring from
conception to 42 days postpartum. Within this period,
women’s health can be compromised by conditions that
arise specifi cally from pregnancy, known as direct obstetric
conditions, or that are aggravated by or threaten pregnancy,
known as indirect obstetric conditions. Direct causes account
for 80 percent of all deaths, with indirect causes accounting
for the remainder. Of direct causes, hemorrhage is the most
common. Indirect causes include diseases such as HIV/AIDS
and malaria.
International experts, writing in the comprehensive report,
Disease Control Priorities in Developing Countries, 2nd
edition (DCP2), focus on fi ve major maternal conditions that
account for an estimated 75 percent of maternal deaths—
hemorrhage, sepsis, hypertensive disorders of pregnancy,
obstructed labor, and unsafe abortion.
Although pregnancy and childbirth are natural processes,
maintaining a balance between handling normal deliveries
and readiness to deal with complications represents a
challenge to health systems and a tension in safe
motherhood programs. Assessments of the features of
maternal conditions must be complemented by attention to
the following characteristics of maternal health:
• Many preventive practices related to pregnancy and
childbirth can be harmful in unskilled hands;
• The lives of at least two individuals are at stake if
complications arise;
• Conditions present clinically not as single entities but
as complexes;
• Death is highly concentrated around the time of
delivery. About two-thirds of maternal deaths occur
between the onset of labor or abortion and 48 hours
postpartum or postabortion.
• The initial clinical presentation of some conditions
can be sudden, with rapid escalation to a life-
threatening state; and
• Maternal conditions are often unpredictable.
Maternal Deaths
An Unacceptable Lack of Progress
Fogarty International Center of the U.S. National Institutes of Health The World Bank World Health Organization Population Reference Bureau | Bill & Melinda Gates Foundation
www.dcp2.org
March 2007
Almost all maternal deaths are avoidable with competent
care, but interventions must address a broad set of issues.
Risk factors for both serious maternal health problems and
potential death can be social, economic, or cultural; and
they can be related to the health system or to the health
condition of the mother. To reduce the risk factors, health
system improvements must be complemented by attention
to wider social, economic, and cultural factors as well as to
reproductive rights.
Almost all maternal deaths occur in the developing world.
This differential in maternal mortality between the developing
and developed worlds is often cited as the largest discrepancy
of all public health statistics. Just 13 countries account for
70 percent of all maternal deaths. Two regions — South
Asia and sub-Saharan Africa — account for 74 percent of
the global burden of maternal conditions (see table). There
are also wide disparities across socioeconomic status within
countries, with large gaps between rich and poor.
Globally, little progress has been made in reducing maternal
mortality over the past 20 years, although there is some
evidence of decline in countries where maternal mortality
ratios were already low (fewer than 100 maternal deaths
per 100,000 live births). Recent World Health Organization
(WHO) statistics on unsafe abortion — a major cause
of maternal mortality — show an apparent decrease in
incidence globally, although the risk of death remains high at
50 maternal deaths per 100,000 live births (and as high as 140
per 100,000 live births in Sub-Saharan Africa).
Interventions
No single health intervention can by itself significantly
reduce maternal mortality. The scope and nature of maternal
conditions call for clusters, or packages, of interventions. Three
main pathways can avert adverse outcomes — preventing
pregnancy, preventing complications, and preventing death
from complications of pregnancy and childbirth. The first
pathway is the only true primary prevention strategy and is
the focus of a forthcoming fact sheet that summarizes the
DCP2 chapter on contraception.
Preventing complications involves maintaining a normal
pregnancy and managing mild complications — in essence,
good quality of care. If complications occur, maternal death
can be avoided by effective, timely, and appropriate clinical
interventions, often referred to as emergency obstetric care.
DCP2 clusters intervention strategies on the basis of:
• Strategic approach — population-based versus
personal interventions;
• Level of care — home, primary, and secondary care;
and
• Time period — pregnancy, labor and delivery,
and postpartum.
The most effective and promising interventions are highlighted below:
Population-Based Interventions
Planning Pregnancies
Research has shown that women face a greater risk of
pregnancy-related death or disability depending on
the frequency of pregnancies (number and spacing),
mother’s age, and desire for the child. Women can better
plan their pregnancies if they are exposed to family
planning information, education, and communication
(IEC) programs, and client-friendly services to increase
access to contraception. These interventions have been
credited with a substantial increase in contraceptive use
and fertility decline in developing countries over the past
40 years. But a significant unmet need for contraceptives
still persists. Experts estimate that avoiding unintended
pregnancies would reduce maternal deaths by 20 percent in
developing countries.
imProving nutrition
Many women in developing countries suffer problems
in pregnancy because of a lack of vital nutrients —
especially iron, iodine, folate, and vitamin A. Limited
evidence supports interventions such as multivitamins,
minerals, or macronutrient interventions, including
protein-energy supplements, as well as iron and folic acid
to combat anemia.
Personal Interventions
Interventions directed at individuals must involve a
continuum of care for mother and baby in terms of time
(before and after delivery), place (linking home and health
services through an effective referral chain), and skilled
personnel (the care provider). Care can be provided in the
home, at the primary level (clinic or health center), and at
the secondary level (district hospital).
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Home-Based care
Birth preparedness includes planning for the place of and the
attendant at delivery, as well as arranging for rapid transport
to a health center or hospital if needed, and sometimes
identifying a compatible blood donor in case of hemorrhage.
The expectant mother, relatives, and other community
members, including traditional birth attendants (TBAs)
should learn to recognize signs of dangerous complications
and to take the appropriate steps.
Primary-level care
Primary-level care is widely regarded as the crucial entry point
to maternity services, and to care before and after pregnancy.
Primary-care level health centers should provide prenatal,
delivery (including managing abortion complications), and
postpartum care (including family planning and postabortion
counseling), as well as care of the newborn.
Management of complications usually occurs at two
levels — basic emergency obstetric care (BEmOC) and
comprehensive emergency obstetric care (CEmOC).
CEmOC includes surgical interventions and blood
transfusion. The capacity of health centers to provide
BEmOC depends on the availability of supplies, drugs,
infrastructure, and skilled providers.
Routine Prenatal Care. Essential elements of routine
prenatal care include: screening and treatment for syphilis,
immunization with tetanus toxoid, prevention and treatment
of anemia, and prevention and treatment of malaria with
prophylaxis or bed nets. Strong evidence supports the cost-
effectiveness of a four-visit prenatal schedule that includes
educating women and birth attendants about danger signs
and the need for skilled attendance at delivery.
Delivery Care. The risks of adverse outcomes for mother
and baby are highest during childbirth. To reduce these
risks, experts recommend that delivery services be provided
by professionals with obstetric skills, whether the birth
occurs at home or in a health facility. A major strategy for
reducing the maternal health burden involves increasing
the use of skilled providers for the vast majority of normal
deliveries and managing mild complications at the primary
level with referral to CEmOC if necessary. Globally, there
are wide variations in skilled attendance at childbirth,
with the lowest being in sub-Saharan Africa at 48 percent
of deliveries. Variation also exists across socioeconomic
groups within countries. The proportion of deliveries with
a health professional (doctor, midwife, or nurse) present is
an indicator used to assess progress in improving maternal
health care.
Postpartum Care. Primary care services continue to neglect
the postpartum period despite significant problems during
this time. Routine postnatal checks are not widespread,
and most contacts with services after delivery focus on
educational messages aimed at danger signs, breastfeeding,
nutrition, and lifestyle, rather than physical examination of
the postpartum woman. Because unsafe abortion accounts
for a significant proportion of the burden of maternal
conditions, management of complicated abortions should
receive higher priority, but attention to this critical need is
often neglected.
secondary-level care
Hospital-based care, generally at the district level, includes
CEmOC, and must include strong links to the primary-
level through an effective rapid referral communication
chain. District hospitals must be able to provide surgical
interventions with the requisite backup, such as blood banks.
Obstetric experts agree that maternal mortality cannot be
reduced without effective secondary care for complications.
The UN has endorsed a minimum of one CEmOC facility
per 500,000 people.
Cost-Effectiveness
Cost-effectiveness analysis focuses on prenatal care, delivery,
or intrapartum care, and emergency obstetric care. The most
cost-effective intervention package relative to an assumed
routine maternity service, improves the quality of prenatal
and intrapartum care by ensuring the availability of BEmOC
at the primary level and by increasing the adequacy of
CEmOC at the secondary level. In South Asia, moving from a
routine maternity service to this package of enhanced quality
of care costs $142 per additional DALY averted and $5017
per additional death averted; and in sub-Saharan Africa, the
costs were $83 per additional DALY averted and $2,729 per
additional death averted. Small increases in prenatal care
coverage, of even 20 percent more women, boost the number
of women benefiting from the addition of obstetric first aid
and CEmOC.
Maternal Mortality | Disease Control Priorities Project | PAGE 3
Benefits of Intervention
Reducing maternal mortality benefits households
economically by allowing women to remain productive
longer and by averting the costs associated with a health
crisis. Because children’s health and education usually suffer
when mothers die, avoiding maternal deaths also avoids
these extra economic burdens. Thus, preventing maternal
mortality can support broader efforts to reduce poverty.
However, gains in maternal health depend on functioning
health systems and a supportive policy environment. Attaining
basic prenatal and delivery coverage for 50 percent of women
costs only $0.41 per capita in South Asia and $0.60 per capita
in sub-Saharan Africa, yet funding for prenatal and delivery
care services is inadequate. Progress depends on a complex set
of factors, including solving human resource problems (the
“brain drain”), effective referral systems, extending access to
services to the poorest groups, improved surveillance, and
additional research.
*1 DALY (disability-adjusted life year) is a composite measure that com-bines the number of years lived with a disability and the number of years lost to premature death.
References
Wendy J. Graham, John Cairns, Sohinee Bhattacharya, Colin
H.W. Bullough, Zahidul Quayyum, and Khama Rogo. 2006.
“Maternal and Perinatal Conditions.” In Disease Control
Priorities in Development Countries, 2nd ed. D. T. Jamison,
J. G. Breman, A. R. Measham, G. Alleyne, M. Claeson, D. B.
Evans, P. Jha, A. Mills, and P. Musgrove, 591-603. New York
Oxford University Press.
www.dcp2.org
Estimates of Maternal Mortality by Region, 2000-2001
RegionMaternal mortality ratio
(maternal deaths per 100,000 live births), 2000
Number of maternal deaths as modeled by
WHO, 2000
Lifetime risk of maternal death
(1 in number shown)
Central and Eastern Europe, Commonwealth of Independent States, Baltic states, Europe, and
Central Asia64 3,400 770
East Asia and the Pacific 110 37,000 360
Eastern and Southern Africa 980 123,000 15
Latin America and the Caribbean 190 22,000 160
Middle East and North Africa 220 21,000 100
South Asia 560 205,000 43
Sub-Saharan Africa 940 240,000 16
Western and Central Africa 900 118,000 16
High-income countries 13 1,300 4,000
Low- and middle- income countries 440 527,000 61
Low-income countries 890 236,000 17
World 400 529,000 74
Source: Graham, W. L., J. Cairns, S. Bhattacharya, C. H.W. Bullough, Z. Quayyum, and K. Rogo. 2006. “Maternal and Perinatal Conditions.” In Disease Control Priorities in Development Countries, 2nd ed. D. T. Jamison, J. G. Breman, A. R. Measham, G. Alleyne, M. Claeson, D. B. Evans, P. Jha, A. Mills, and P. Musgrove, table 26.2. New York: Oxford University Press.
Note: The regions are those used by the United Nations Children’s Fund.