REGIONAL COMMITTEE Fifty-third Session
Provisional Agenda item 14 SEA/RC53/11 13 July 2000
REGIONAL STRATEGY FOR REDUCTION OF MATERNAL MORTALITY IN THE SOUTH-EAST ASIA REGION
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CONTENTS I. 2. 3. 4. 5. 6. 7. THE PROBLEM: MATERNAL DEATH.........................................................................................1 PROGRESS: SAFE MOTHERHOOD INITIATIVE......................................................................2 MATERNAL DEATHS: CAUSES AND NATURE........................................................................3 INTERVENTIONS..........................................................................................................................3 DISCUSSIONS ..............................................................................................................................5 PERSPECTIVES: THE WHO MAKING PREGNANCY SAFER (MPS) STRATEGY ...............5 PROPOSED STRATEGY FOR REDUCING MMR IN SEAR COUNTRIES.............................7 7.1 7.2 7.3 7.4 7.4 8. Objective ................................................................................................................................7 Goal ........................................................................................................................................7 Target .....................................................................................................................................7 Expected Outcomes ..............................................................................................................7 Action Points ..........................................................................................................................7
CONCLUSIONS ..........................................................................................................................10
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I.
THE PROBLEM: MATERNAL DEATH
Although pregnancy is not a disease, pregnancy-related deaths constitute the leading cause of loss of healthy lives among women of reproductive age in the South-East Asia Region [SEAR]. This Region alone accounts for 40 per cent of the global maternal deaths1, the highest among the six WHO regions. Seven out of the ten SEAR countries show a Maternal Mortality Rate (MMR) of more than 100 per 100 000 live births2 - five of these are least developed countries.
Maternal Mortality Ratio (MMR) SEAR Countries, 1995
Thailand
Sri Lanka
Myanmar Maldives
Bhutan
Bangladesh Indonesia
India
Nepal
Source: WHO SEARO Regional Health Reoport, 1997
The national aggregation of MMR is just the tip of the iceberg as maternal deaths are grossly underreported due to non-registration and/or incorrect classification. One study has indicated that more than 70 per cent of maternal deaths are underreported3. Besides, the national MMR averages comprise variations among women from different geographic regions, social classes and indigenous and ethnic groups. For example, the national MMR average of 408 for India is found to comprise variations ranging from 29 in Gujarat to 707 in Uttar Pradesh4. With nearly half of the world’ s poor inhabiting the Region, women constitute a much higher proportion of the poor. Research also shows that women from the world’ s poorest households with income less than US$1 a day are, at least, 300 times more likely to die of pregnancy and childbirth-related causes.
Maternal death is defined as “death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggrevated by the pregnancy or its management, but not from accidental or incidental causes” – ICD-9 and ICD-10. ICD-10 introduced pregnancy-related deaths as “death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death”. 2 WHO SEARO Regional Health Report, 1987. 3 Maternal Mortality & Morbidity Study, His Majesty’ s Government of Nepal, 1998 4 Sample Registration Bulletin, April 1999, Registrar of India
1
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Some 80 per cent of pregnant women in SEAR suffer from nutritional anaemia, which is a major contributor to maternal deaths and low birth weight5.
Prevalence of Anaemia in SEAR and other WHO Regions
The prevalence of low birth weight ranges from 7 to 50 per cent in SEAR countries6. Despite the growing awareness about equal rights for women, gender discrimination remains a major public health problem. The appallingly high maternal mortality ratios existing in the Region tellingly reflect, among others, the gender discrimination women suffer, starting even before their birth. The grim statistics of maternal mortality also speak of the silent death of a large proportion of infants. Over 50 per cent of infant deaths in the Region occur during the neonatal period, nearly two-thirds of which occur within the first week of birth, mostly due to perinatal causes7. 2. PROGRESS: SAFE MOTHERHOOD INITIATIVE
Despite the complexities of the problem, the Safe Motherhood Initiative [SMI] has covered much ground since 1987. A series of advocacy conferences, as well as research initiated at international and national levels in the late 1980s and early 1990s, have put safe motherhood on the national and international health agenda. The MMR now forms one of the human development indicators in country-assistance strategies of other UN agencies including the World Bank. The countries in the South-East Asia Region have accorded high priority to reducing maternal deaths. The Declaration on "Health Development in the South-East Asia Region in the 21st Century" has identified maternal mortality reduction as one of the five foremost challenges advocated for public health actions. This Declaration was adopted in 1997 for joint action by Health Ministers of all the ten countries in the Region.
5 6
WHO Geneva, Global database on anaemia, 1997. WHO SEARO Nutrition in South-East Asia, 1999. 7 WHO/SEARO Regional Health Report, 1996.
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The Regional Standards for Midwifery Practice, developed and field-tested in collaboration with several countries, have identified some basic prerequisites for their application at all levels of health systems. Dr Gro Harlem Brundtland, Director-General, World Health Organization, through her initiative of the WHO Making Pregnancy Safer [MPS] Strategy, has endeavoured to revitalize WHO’ s commitment to ensure women’ s right to life. As a result, maternal health is now one of the WHO corporate priorities in terms of resource investment. 3. MATERNAL DEATHS: CAUSES AND NATURE
A decade of research on Safe Motherhood has provided a rich knowledge base, some of the highlights of which are as follows: • Globally, more than 80 per cent of all maternal deaths are due to direct obstetric complications: haemorrhage, infections, unsafe abortion, eclampsia and obstructed labour and other direct causes. • A major proportion of these deaths occurs either at home or in transit. Nepal’ s study on maternal mortality and morbidity has shown that 67.4 per cent of maternal deaths occurred at home3. • Globally, 61 per cent of maternal deaths occur in the postpartum period, more than half of which take place within one day of delivery8. • Some 15-20 per cent of all pregnancies develop sudden obstetric complications, which cannot be predicted. This implies that every pregnancy should be monitored regularly, ensuring timely detection of life-threatening symptoms and timely interventions. • Some disturbing new information shows that a high proportion of maternal deaths (15.7 per cent) is attributable to domestic violence9. • About 40 to 50 per cent of girls in some SEAR countries are married and become pregnant before they reach the age of 20. Research shows that a pregnant adolescent is two to five times more likely to die than a woman between 20 and 25 years. • Though not reported widely, unsafe abortions constitute a significant proportion of maternal deaths. Deaths due to unsafe abortions indicate, among others, a high level of unmet needs for family planning services of good quality. 4. INTERVENTIONS
The next question relates to whether specific proven interventions exist to prevent such avoidable deaths and disabilities? Epidemiologically, the nature of maternal deaths is complex. The prevention of maternal deaths requires a set of strategies consisting of both preventive and curative interventions and which must be accessible within a short time after the onset of symptoms.
8 9
Maternal Health Around the World (Wall-chart), WHO, Geneva, 1997 Community-cum-hospital-based case control study on maternal mortality, Ganatra B.R., Coyaji K.J., and Rao V.N., KEM Hospital Research Centre, Pune, December 1996
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A review of basic models of maternal care in countries which were able to cut down their MMR, including Sri Lanka, provides some lessons on what has worked on reducing maternal deaths. This review shows that the MMR in Sri Lanka fell from a level of over 1 500 per 100 000 live births in 1940-1945 to 555 per 100 000 by 1950-1955 and to 95 per 100 000 by 1980.
Source: WHO 99020
The specific interventions relating to the main causes of direct obstetric deaths are summarized in Table 1. Table 1. Maternal Deaths – Causes and Main Interventions Causes of Maternal Deaths Bleeding after delivery (postpartum haemorrhage) %age 25 Proven Interventions Treat anaemia in pregnancy. Skilled attendant at birth: prevent/treat bleeding with correct drugs, replace fluid loss by IV drip/transfusion, if severe. 15 Skilled attendant at birth: clean practices. Antibiotics, if infection arises. Unsafe abortion High blood pressure (hypertension) during pregnancy: most dangerous when severe (eclampsia) Obstructed labour Other direct obstetric causes 13 12 Skilled attendant: give antibiotics, empty uterus, replace fluids if needed, counsel and provide family planning. Detect in pregnancy: refer to doctor or hospital. Treat eclampsia with appropriate anticonvulsive (MgSO4); refer unconscious woman for supervised, urgent delivery. Detect in time, refer for operative delivery. Refer ectopic pregnancy for operation.
Infection after delivery
8 8
Source: Making Pregnancy Safer : A Sector Health Strategy for Reducing Maternal and Perinatal Morbidity and Mortality, WHO, July 2000.
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The interventions with proven impact on reducing newborn deaths are summarized in Table 2. Table 2. Newborn Deaths – Causes and Main Interventions Causes of Newborn Deaths Infections (Sepsis meningitis, pneumonia, neonatal tetanus, congenital syphilis) Birth asphyxia and trauma Pre-term birth and/or low birth weight %age 33 Proven Interventions Maternal TT immunization, syphilis screening and treatment, clean delivery, warmth, support for early and exclusive breast-feeding, early recognition and management of infections. Skilled attendant at birth. Effective management of maternal obstetric complications. Antimalarials for women at risk. More attention to warmth, breast-feeding, counselling and support, infection control and early detection and management of complications.
28 24
Source: Making Pregnancy Safer : A Sector Health Strategy for Reducing Maternal and Perinatal Morbidity and Mortality, WHO July 2000.
Clearly, some 80 per cent of both maternal and neonatal mortality could be prevented if these interventions could be utilized timely by all women and babies in need. 5. DISCUSSIONS
Despite the development and existence of such cost-effective interventions, they are not yet available to all women in need. Although there is an impressive establishment of health infrastructures in countries of the Region, their capacity to provide basic maternal health care, especially essential obstetric care, is often lacking. Even where such services are available, women in need cannot access them timely, mainly due to the lack of referral systems and their low socioeconomic status. Dr Brundtland has aptly described that maternal mortality is an indicator not only of women’ s health, but also of access, integrity and effectiveness of the health sector. With deepening poverty among women, there is a compelling need for instituting alternative means and mechanisms for fair financing so that none, in need, are barred from accessing the life-saving essential elements of obstetric care. The estimated cost for the entire package of such interventions in low-income countries is about US$ 3 per person per 10 year . Research shows that more maternal deaths occur as a result of the "three delays" in the SEA regional context: delay in deciding to seek medical care; delay in reaching medical facility with adequate care, and delay in receiving quality essential obstetric care3&8. 6. PERSPECTIVES: THE WHO MAKING PREGNANCY SAFER (MPS) STRATEGY
The WHO MPS strategy offers a practical health sector response to resolving the above 10
WHO’ s Mother-Baby Package, Geneva, 1994
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issues. The MPS strategy builds upon the consensus reached at the International Conference on Population and Development [ICPD-Cairo, 1994, the Fourth World Conference on Women (Beijing, 1995) and the joint WHO/UNFPA/UNICEF/World Bank Statement]. It describes the contribution WHO intends to make during the next biennia to the worldwide Safe Motherhood Initiative movement. The key messages of Making Pregnancy Safer are: • Every pregnancy should be wanted. • All pregnant women and their infants should be able to access skilled care. • All women should be able to reach a functioning health facility to obtain appropriate care for themselves or their newborns when complications arise during pregnancy, delivery or the postpartum period. The said strategy calls on all partners, i.e. national politicians, government, the civil society, community leaders, women’ s groups and international partners, for action in achieving jointly the globally committed goals in maternal and infant mortality reduction which are as follows: • To have skilled attendants present for 80 per cent of childbirths by the 2005. • Where there is very high maternal mortality, at least 40 per cent of all births should be assisted by skilled attendants by 2005, at least 50 per cent by 2010 and at least 60 per cent by 2015. • To have reduced the 2000 level of pregnancy-related mortality by 75 per cent by 2015. • To have reduced infant mortality rate below 35 per 1 000 live births by the year 2015. Building upon the existing efforts within countries to achieve the goal of maternal and infant mortality reduction, the Making Pregnancy Safer initiative will assist governments to increase their capacity to: • Establish (or update) national policy and standards for family planning, induced abortion (where not against the law), maternal and newborn care (including postabortion care), and develop a combination of regulatory measures to support these policies and standards. • Develop systems for ensuring that these standards are properly implemented. • Improve access to effective maternal and newborn care and fertility regulation services through promoting increased investments in public sector and the development of arrangements (such as contracting) to maximize the contribution of the private health sector to national goals. • Encourage home/family – and community – level practices that promote maternal and newborn health, and fertility regulation. • Improve systems for monitoring maternal and newborn health and care services, including fertility regulation services. • Keep safe motherhood high on the national health and development agenda.
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7.
PROPOSED STRATEGY FOR REDUCING MMR IN SEAR COUNTRIES
Against the above backdrop, an attempt has been made here to effectively respond to the existing needs for quality maternal and neonatal health care in countries of the Region. The strategy as well as the actions suggested here build upon the existing national policies and goals and the ongoing activities. They relate to the goals of the ICPD, Cairo 1994, FWCW, Beijing 1995 and the Joint WHO/UNFPA/UNICEF/World Bank Statement. The WHO MPS provides the framework for the suggested regional strategy.
7.1 Objective The overall objective of the regional strategy is to intensify WHO’ s collaborative work for contributing to national efforts for the reduction of maternal mortality in the high-MMR countries in the Region.
7.2 Goal To contribute to the efforts countries are making to achieve the globally agreed goals in maternal and infant mortality reduction.
7.3 Target At least 40 per cent of all births would be assisted by skilled attendants by the end of 2005.
7.4 Expected Outcomes The high-MMR countries, together with WHO and other partners, to have: • improved cooperation and coordination at the national level, including mechanisms for monitoring and evaluation; • strengthened health systems through the development of coordinated policies, strategies and plans, improvement of human resource development and establishment of referral and supervisory systems for maternal and neonatal morbidity and mortality reductions; • improved quality and coverage of maternal and neonatal health care through adapting evidence-based interventions like the WHO Standards of Midwifery Practice, and • developed and adequately disseminated home/family and community-based messages and interventions to improve maternal and neonatal health practices.
7.4 Action Points (1) Advocacy • To support/motivate national leaders, politicians and international agencies to speak out about the shocking differences of maternal and newborn mortality between and within countries.
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• To include MMR as one of the indicators of national development policy and plan. • To mobilize the policy and resources support from all partners for introducing the proven and affordable interventions into the functioning of health systems. • To stress the need of skilled attendants at childbirth and establishing a functioning and accessible back-up system. • To mobilize communities and village development councils to support transport and communication to improve access to care for women and their babies. • To empower women and men with knowledge and information so that they know “ What” type of maternal and newborn health care needed, and “ How” and “ When” to
obtain these from “ Where” during pregnancy, childbirth and after childbirth including contraceptive services of one’ s choice. • To encourage home/family members, i.e., husbands, fathers-in-law, mothers-in-law and other community leaders for mobilizing their timely actions for registering all pregnant women for early check-up, detection and referral of women with danger signs and symptoms, including organizing local provision for emergency obstetric transportation. • To promote free and informed choice of timing and spacing of pregnancies.
(2)
Strengthening of Health Systems • To establish/update national policy and standards for maternal and newborn care, including family planning and prevention and treatment of unsafe abortion. • To establish basic and comprehensive essential obstetric care at the first referral and district hospital levels and place a skilled attendant at every childbirth. • To develop a combination of regulatory measures to support these policies. • To introduce the SEARO Standards of Midwifery Practice for application at various levels of health systems. • To introduce systems for ensuring that these standards are properly implemented at various levels of health systems. • To develop mechanisms and linkages of health systems with village and district development councils, community health volunteers, mothers’ groups, NGOs and other private organizations for mobilizing support for pregnancy mapping, referral and notification of maternal deaths, if any. • To establish systems for clinical and community audit of maternal deaths. • To incorporate into national health information system a list of outcome indicators covering health system performance, quality and coverage, partnership mobilization/coordination, family and community participation for maternal and newborn health care, including contraceptive services. • To ensure, through training, the availability of adequate number and mix of human resources for the provision of quality basic and comprehensive essential
obstetric care, upwards of the community level.
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(3)
Research and Development • To develop an integrated package of proven interventions which can be implemented within the context of a country-specific health system. • To assess and evaluate whether the implementation of such interventions through country-specific health systems has improved the access and utilization of maternal health care services. • To conduct studies on differentials in the access and utilization of maternal health care among pregnant women in different geographical locations, social classes, and indigenous and ethnic groups.
(4)
Mainstreaming the Maternal Health Concern • To educate health workers, at various levels of the health system, on TB, malaria, nutritional anaemia, diabetes and HIV/AIDS, and substance abuse including tobacco, as these diseases comprise about 18 per cent of indirect causes of maternal mortality. • To incorporate these interventions into the functioning of a health system as essential components of maternal and newborn care. • To update national lists of essential drugs, including contraceptives, and equipment needed for reducing maternal and newborn mortality and morbidity. • To strengthen the provisions of safe blood and laboratory services in district health systems.
(5)
Monitoring • To assess the progress made in the implementation of the plan of action as programmed. • To take actions as appropriate to improve the implementation. • To assess the increase/decrease in the number of partners at country level who participate in the implementation of national strategic plan to reduce maternal and neonatal mortality and morbidity. • To assessing the trend in the overall level of financial support available from all sources/partners for the implementation of national plans of action. • To assess the quality and coverage, particularly the trend in the number of the poorest women who were able to utilize the basic and emergency obstetric care.
(6)
Building Partnerships • To jointly develop with partners a common framework of action plan, within the context of national plans and policies, to reduce maternal and neonatal mortality and morbidity. • To increase the overall level of financial support from all partners for the implementation of interventions defined in the national plan of action for the reduction of maternal and neonatal mortality and morbidity.
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• To coordinate the implementation of the common plan of action so that the minimal range of an acceptable standard of critical health interventions reaches timely to all women and their babies in need, including safe and effective fertility regulating methods of one’ s choice. • To enable women and their babies, particularly the neediest, to access these health interventions. • To help pregnant women in danger to quickly reach the health care facility. 8. CONCLUSIONS
In conclusion, a brief recapitulation of the ideas that emerged during this review is in order. • The maternal mortality ratio in countries of the Region is unacceptably high. The Region accounts for 40 per cent of the global maternal deaths, the highest among the six WHO regions. In Dr Brundtland’ s words, “ maternal mortality is an indicator not only of women’ s health but also of access, integrity and effectiveness of health sector. ” • Some 80 per cent of all maternal deaths are due to direct obstetric complications: haemorrhage, infections, unsafe abortion, eclampsia, obstructed labour and other direct obstetric causes. Safe and affordable interventions to prevent these deaths do exist. • These proven technologies, however, are not yet accessible to a large majority of women and babies in need. Despite the impressive establishment of health infrastructures in countries of the Region, such life-saving interventions are not yet found at various levels of district health systems, particularly in high MMR countries. The WHO-proposed regional collaborative programme for the biennium 2000-2001 addresses very compelling issues. These include: support to conduct operational research on community and facility-based interventions for Making Pregnancy Safer; strengthen the district health systems by adapting the WHO Standards of Midwifery Practice for the delivery of quality maternal and neonatal health care, and develop and disseminate advocacy materials for promoting the MPS strategy for adaptation to the country-specific situation. The proposed regional strategy calls for concerted efforts from all partners in putting the existing proven interventions into a single package, and mainstreaming it through different levels of health systems. Its effective application at the ground would make a difference: difference in making every pregnancy safer, in saving lives, and in improving the potential of future generations.