The Millennium Development Goals (MDGs), in particular MDG 5, have sharpened the world’s focus on the critical need to reduce maternal mortality. Commitments have been made. One hundred and eighty nine countries signed on to the MDGs, committing their governments to achieving a 75% reduction in maternal mortality (based on the 1990 figure) by the year 2015. International development partners have committed significant resources towards decreasing the number of women and newborns dying as a result of obstetric complications. NGOs have committed to advocating for action globally and locally to reduce maternal deaths. And at national levels in most developing countries there exists a strategic plan, a Road Map, a programme of work, even a budget—all geared towards reducing maternal mortality. But there has been little action. There is a huge gap between the plans and the actions, the rhetoric and the reality. It is generally recognized that of all the MDGs, progress towards meeting MDG 5 is deemed to have stalled.1
And yet the causes of maternal deaths are known, the interventions have been clearly articulated and the WHO estimates that 88–98% of maternal deaths are preventable.2 Direct obstetric causes, which make up about 80% of all maternal deaths, are due to haemorrhage, pregnancy related hypertension and eclampsia, sepsis, complications secondary to unsafe abortions and obstructed labour. Increasingly in some countries, women are also dying of causes related to HIV or malaria.
There is general consensus that a three-pronged strategy is necessary to reduce these maternal deaths: All women must have access to contraception to avoid unintended pregnancies; all pregnant women must have access to skilled care at the time of birth; and all women who experience complications in pregnancy and childbirth must have timely access to quality emergency obstetric care.3 This in turn requires a functioning and sustainable health system that engages communities and facilities4 and that makes sure that health services are accessible to all women where the notion of accessibility encompasses principles of affordability, acceptability and availability.
The task is enormous. In many developing countries, the capacity of health systems to respond to the quiet tsunami of maternal deaths is questionable. In these countries, health systems have deteriorated over the past three decades, some as a result of conflict, others because of a systematic undermining of government health systems and, in a handful of countries, as a result of inadequate governance.
Strengthening health systems will take more than simply tinkering around the edges. It will require a fundamental reframing of how governments perceive health systems, the health care they deliver, and specifically how they take action to reduce maternal deaths. As Lynn Freedman indicates, it is no longer about “business as usual”.
Why the need to reframe the way in which governments and development partners think about health systems? In short—history matters.
In 1985, at the end of the UN Decade for Women, the World Health Organization (WHO) reported that over 500,000 women per year were dying as a result of obstetric complications. In the same year, Allan Rosenfield and Deborah Maine published their seminal article, “Maternal Mortality—A Neglected Tragedy: Where is the M in MCH [Maternal and Child Health]?”,5 challenging public health specialists to explain why most of the interventions traditionally bundled into maternal health care packages benefited the child and failed to address the key causes of maternal deaths. These two critical events galvanized the international community to focus on this previously disregarded and hidden crisis and led to the 1987 Safe Motherhood Conference in Kenya.6
The Nairobi Safe Motherhood Conference launched the Safe Motherhood Initiative which, in turn, saw the formation of the Safe Motherhood Inter-Agency Group and a series of regional and national conferences that sought to entrench safe motherhood as an “accepted and understood term in the public-health realm” and core component of reproductive health.7 In her paper, “Safe Motherhood Initiative: 20 Years and Counting”,8 Starrs describes how public health specialists and women’s health advocates worked together to develop a comprehensive approach to reducing maternal deaths. This broad approach required action within the health systems—expanding the core elements of maternal health including antenatal care, clean, safe delivery, essential obstetric care and postnatal care from within the community through to the referral levels, as well as action to increase women’s status, provide good nutrition to young girls, educate communities and provide family planning.
And yet, more than twenty years later, the WHO continues to report that over 500,000 women per year die as a result of obstetric complications.9 The overall picture has barely changed. WHO reports that 99% of these deaths occur in developing countries, 13 countries account for 67% of the deaths.10 Further analysis of these numbers reveals huge inequities in the maternal mortality ratios (MMRs) between developed and developing countries, and similar orders of difference within countries—urban to rural. Whereas women in the developed world face MMRs of less than 20 deaths per 100,000 live births, translating into a lifetime risk of death of less than 1 in 7,300, this risk of dying increases exponentially to higher than 1 in 22, with MMRs soaring over 1,000 maternal deaths per 100,000 live births for women in many developing countries, especially parts of Africa and Asia.11 Where there has been a small decrease in the maternal mortality ratio over the past 10 years—an average of 1% decline per year, this decline is amongst countries that already have relatively low levels of maternal deaths.12
What Went Wrong?
Maine and Rosenfield argue that the Safe Motherhood Initiative lacked strategic focus,13 especially if compared to the successful Child Survival Initiative. The Child Survival Initiative provided government and international agencies with a compact set of interventions that stopped children from dying, interventions captured under the acronym GOBI—growth monitoring, oral rehydration, breast-feeding and immunization—all of which could be delivered, if necessary, in the community and outside of a health facility. In comparison, the Safe Motherhood initiative was much broader, each action “clearly worthy and important goals, (but) only one, essential obstetric care, includes actions that can substantially reduce maternal deaths.”14
Without a strategic focus, the Safe Motherhood Initiative was carved up into a menu of separate interventions from which donors, international agencies and governments could select, usually according to their resource levels, political expedience and, perceived cost-efficient “quick wins” and short cuts. Often excluded from the menu selection were the more “controversial” interventions, including access to family planning and provision of safe abortion care. Anti-abortionists came to regard safe motherhood as the Trojan horse for the introduction of legal abortion, and donors and international agencies became wary of providing support to the Safe Motherhood Initiatives.15