|02. Of Blind Alleys and Things that Have Worked: History's Lessons on Reducing Maternal Mortality|
Clearly maternal mortality was not a matter of public concern up to the late 1970s, in spite of the fact that it was broadly at the level which had given rise to major political pressure in Sweden in the XIXth century and in Britain in the early XXth. Various factors may have contributed to this.
First, information was hard to come by. Vital statistics in developing countries were - and still are - very much incomplete. In 1977 only 66 countries out of 162 provided (incomplete) data on maternal mortality: in Africa 5 out of 52, in Asia 13 out of 43 and in Latin America 19 out of 31 (Rochat 1981). In those days the only data on maternal mortality in developing countries came from hospitals (Kwast 1988), without the denominator that could give a population perspective. Given the weakness of routine registration, there have been major efforts to provide estimates of maternal mortality through, a.o. the DHS surveys.
This kind of information is, however, much less effective for generating corrective action than, e.g., the confidential enquiries that became routine in the UK at the end of 1950s (Godber 1994). It is even less effective than the data that were available in Sweden in the XIXth century. First, to estimate maternal mortality through surveys is demographers work, often performed by foreign experts, with little ownership by authorities, national medical establishment or civil society. This greatly reduces their impact. Second, maternal mortality ratios only indicate the magnitude of the problem, not its vulnerability. They do not encompass the notion of avoidable deaths that their combination with clinical experience and enquiries in maternal deaths carried in, e.g., the UK. Third, survey estimates do not provide the degree of disaggregation necessary for planning and priority setting or for mobilising local authorities to respond to their particular situation. To know that 21 women died in a year in one particular district is information of a different kind than to know that MMR is estimated at 530 in the country. The sampling errors are such that even DHS survey estimates cannot be used for more than trend assessment over 10 year-intervals (Stanton et al. 2000).
Second, there is what Graham calls the measurement trap (Graham & Campbell 1992) in translating the information into priority setting. Infants under one appear to run a much greater risk of dying than mothers when mortality quotients or rates are measured; for the maternal mortality rates relate to only one pregnancy at a time and not to the total number of pregnancies a mother may have in the course of her life.
As a matter of fact the problem was grossly underestimated. Around 1980 many in academic circles still thought maternal mortality in poor countries was of the order of magnitude of 300/100,000 (Rao 1981, Rosa 1981). Furthermore, donor agencies, planners and a substantial part of the scientific community considered that it was easier to have an impact on the mortality of children than on that of mothers; for child mortality seemed to respond rapidly and visibly responds to a range of vertical programmes (Walsh & Warren 1979). At that time, the 1980s, the international development world was arguing about the correct interpretation of the concept of primary health care (Van Lerberghe 1993, Van Lerberghe & De Brouwere 2000). In the meantime things medical, and especially hospitals, were decidedly unfashionable (Van Lerberghe et al. 1997).
If the scientific world and the planners have been slow to appreciate that they were failing to address a huge problem, the same can be said of the health professionals. In developing countries there have been no pressure groups of health professionals comparable to those which were active in Britain and the United States in the early XXth century. Among specialists in the large hospitals in the capitals quality of care was not a key feature of the medical culture, and it was rare for quality standards to be promoted or monitored. Practitioners in the district hospitals have many priorities, and the lack of resources rapidly leads to fatalism, certainly for problems that are not immediately visible. Health care providers in the hospitals of developing countries do not expect large numbers of maternal deaths. They are statistically rare (Rosenfield 1989) and doctors are not directly confronted with such occurrences: most of the women who die, do so at home, not in the hospital. The lack of visibility (Ebrahim 1989) is quite convenient in a context where womens lives are valued poorly, high fertility is culturally rewarded, and health professionals have little in common with their client populations.
The turning point came with the Where is the M in MCH? paper of Rosenfield and Maine (Rosenfield & Maine 1985, WHO 1986) and Mahlers appeal for the Safe Motherhood Initiative in 1987 (Mahler 1987). Ten years later it had become difficult to ignore that a major challenge had to be dealt with. But it was clear, too, that many of the past strategies in poor countries had failed.