Lessons learned

The significant reduction of maternal mortality - in an industrial or developing country - requires an active effort, one that can be managed with limited resources. Past macroeconomic growth in industrial countries did not, by itself, reduce maternal mortality. Increased availability of midwives trained to assist in home deliveries and the introduction of aseptic techniques led to a dramatic decline in maternal mortality in Sweden in the eighteenth and nineteenth centuries (Högberg and Wall 1986, Högberg, personal communication 1992). In the 1930s, maternal mortality fell in England, the Netherlands, and other European countries when antibiotics for infections, blood transfusions for hemorrhage, and improved surgical techniques for cesarean section became available (Loudon 1991). Modern family planning and safe abortion services later reduced maternal mortality further.

Socioeconomic improvements are no substitute for family planning and quality health care during pregnancy, delivery, and postpartum. Even in an industrial country, the morbidity and mortality associated with pregnancy and childbirth are high if obstetric care is not used. In the United States, in 1983, well-nourished, well-educated, and relatively affluent women of a fundamentalist religious sect had a maternal mortality ratio of 872 - compared with a national level of 8 - per 100,000 live births because they did not believe in obstetric or other modern medical care (Kaunitz and others 1984).

If a developing nation allots scarce resources appropriately, relatively low maternal mortality rates can be achieved. Appropriate services need to be easily accessible to all pregnant women, or pregnant women must be able to move closer to them when necessary.

Concentrating medical attention only on women identified as at risk has not proved effective. This is because the criteria for risk are often broadly defined and are not closely linked with adverse outcome. Recent studies have found that most of the women who are identified as having "risk factors" do not actually develop life-threatening complications and that a majority of pregnancy-related deaths result from unpredicted complications, that is, among women not identified as "at risk." Thus, risk screening is useful only when based on demonstrated risk factors and combined with monitoring, referral, and prompt treatment to deal with complications as they develop, whether predicted or not (see box 2.2 in chapter 2).

In a study of non-hospital birth centers in the United States, about one of thirteen "low-risk" women - who had an average of eleven prenatal visits - developed a serious complication (Rooks and others 1989). In Zaire, a study to predict complications during pregnancy found the best predictor was a history of problems in previous pregnancies. These women were nine times more likely to suffer obstructed labor. Still, more than two-thirds of the women with obstructed labor had been identified as low-risk (Maine 1991).

In Guatemala, referral following prediction by traditional birth attendants of complications based on demographic risk categories - for example, age or the number of previous deliveries - would overwhelm the service delivery system. Instead, a project in the rural highlands bases referrals on the detection of complications of pregnancy or delivery. There are no certified midwives at health centers in Guatemala who can assist with prenatal screening (Schieber 1991).

In a rural subdistrict of Bangladesh, maternal mortality has declined substantially in the past ten years because of new approaches to family planning and maternity care. An effective community-based family planning project has raised contraceptive prevalence to above 50 percent in the study area - compared with 23 percent in the control area - and reduced the maternal mortality rate (maternal deaths per 100,000 women of reproductive age) by about one-third. Family planning succeeded in decreasing total pregnancies, and thus the number of pregnancy-related deaths, but did not change the risk of death faced by women, once pregnant (Fauveau 1991).

In addition, an effective community-based maternity care project - added to the family planning program - reduced the risk of dying once pregnant (the maternal mortality ratio) by twothirds. The combination of basic family planning and maternal care cut the maternal mortality rate by more than one-half. The maternity care project posted trained midwives in the community to assist women with births in their homes, if requested. The midwives provided prenatal care, carried supplies to stabilize or treat women with complications, and had access to transport and referral services for cases they could not manage (Fauveau 1991).

Other projects have contributed knowledge about effective - and ineffective - interventions (appendix 2). In Indonesia, training traditional birth attendants in the absence of skilled backup support did not decrease women's risk of dying once pregnant (Alisjahbana 1991). In the Gambia, a similar approach helped reduce excessively high maternal mortality ratios, but only to a still relatively high level. There, trained traditional birth attendants provided monthly prenatal care visits to pregnant women. Each woman was also examined by a physician and treated for any illness identified. While this care resulted in a reduction of the maternal mortality ratio from 2,230 to 1,052 deaths per 100,000 live births, it remained excessively high because women who developed complications during late pregnancy or delivery could not obtain the care they needed in time (Greenwood 1991).

In Ethiopia and Nigeria, maternal mortality was reduced through prenatal screening of demonstrated risk factors and identification of danger signs (see box 2.2) - provided by certified nurse-midwives working with traditional birth attendants at the health-center or community level. The screening identified women with poor obstetric histories, and very young and very short women giving birth for the first time, discerned medical problems or complications, and referred the women before the onset of labor (Poovan, Kifle, and Kwast 1990, Brennan 1991). In the program in Ethiopia, maternity waiting homes near a rural referral hospital or health center are successfully used by women who live far away. The community constructs and maintains the homes. Thus, men have contributed financing and labor and are thus more likely to allow their wives to use the facilities (Poovan, Kifle, and Kwast 1990).

In Zaire, women's lives have been saved by delegating essential obstetric care - cesarean sections - to nurses who were readily accessible to women during birth (White, Thorpe, and Maine 1987). In Kenyatta National Hospital, Nairobi, substantial health care resources were being used to manage incomplete abortions. After introduction of the manual vacuum aspiration technique, clients and providers have benefited from shorter hospital stays, better results, and costs that have been reduced by 23 to 66 percent. Given these substantial savings, a Ministry of Health task force developed a plan to extend manual vacuum aspiration training and service delivery to all Kenyan hospitals (IPAS 1991).

In Zaria, Nigeria, the incidence of women diagnosed at the district hospital with obstetric fistulae, a common consequence of prolonged labor, was alarmingly high. Prolonged labor also contributes to maternal mortality. A radio campaign was developed to alert women to the dangers of a labor lasting more than twenty-four hours. In the several years following the campaign, the incidence of obstetric fistulae decreased significantly at the hospital serving the area of the campaign. There was no corresponding decrease at hospitals outside the reach of the campaign (Harrison 1986).

In Lahore, Pakistan, a nongovernmental organization, the Maternal and Child Welfare Association of Pakistan, established a program to provide family planning and maternal and child health services to urban slum dwellers out of reach of public services. Over three years, the association increased the contraceptive prevalence rate by 50 percent and reduced infant and maternal mortality rates, relying entirely on indigenous organizational and financial support (MCWAP 1992).

In Tunisia, the Faculty of Medicine in Sousse has institutionalized postpartum care in the family planning and maternal and child health program. The doctor or midwife who attends the birth schedules as postpartum visit for the mother and infant forty days after the birth. (In Tunisia, this marks the end of the traditional period of seclusion of the mother and her newborn.) As a result, the proportion of women and infants who receive postpartum care as well as family planning and other appropriate health care has increased substantially.

Lessons from ongoing demonstration projects in developing countries confirm the need to ensure women's access to:

· Information and education to promote health practices for safe motherhood.
· Family planning services and appropriate abortion management (appropriate treatment for complications of unsafe abortion and safe services for pregnancy termination, where legal).
· Skilled assistance during pregnancy, delivery, and the postpartum period.
· Referral services and transport for complications and emergencies.

Although all safe motherhood programs in the developing world need these priority elements to reduce maternal mortality, the exact strategy developed by a country will depend on its requirements and resources. The model presented in the next chapter illustrates the events leading to maternal deaths and the factors that should be considered in developing strategies to save lives.