The Hard Road to Lowering Maternal Mortality

Approximately 800 women in the world will die today from preventable causes related to pregnancy, according to the WHO. Recognizing the magnitude of preventable maternal deaths that occur worldwide, the United Nations recently adopted a target to reduce the global maternal mortality rate (MMR) to less than 70 maternal deaths per 100,000 live births by 2030, from its current level of about 210. While this target, which is a part of the Sustainable Development Goals (SDGs), is laudable, past experience shows that it would be naïve to expect quick advances on the road to lowering the global MMR.

The U.N. defines maternal death as "the 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, aggravated by the pregnancy or its management, but not from accidental or incidental causes.” Achieving the SDG target will require reducing global MMR by an annual average of 7.5 percent between 2016 and 2030, more than three times the 2.3 percent annual rate of reduction observed globally during the implementation of the WHO’s Millennium Development Goals (MDGs) between 1990 and 2015. And although global MMR rates (per 100,000 live births) fell from 380 to 210 during the MDG era, this 44 percent reduction fell considerably short of achieving MDG Goal 5A, which aimed to reduce MMR by 75 percent during this 25-year span. In fact, only 9 countries achieved the MDG target – Bhutan, Cambodia, Cabo Verde, the Islamic Republic of Iran, the Lao People’s Democratic Republic, Maldives, Mongolia, Rwanda, and Timor-Leste. Other countries have seen very little progress. A recent U.N. report categorized 47 developing countries— some of which still have a MMR of over 500 maternal deaths per 100,000 live births, such as Chad and the Central African Republic—s having made “insufficient progress” or “no progress” at all.

Why has the MMR remained stubbornly high in so many places, and how can more lives be saved in the future? To understand this, we must go behind the numbers. Saving a pregnant woman’s life is quite different from many other “quick-win” interventions like enrolling a girl in school, vaccinating a child, or dispensing an insecticide-treated bed net. This is true because a woman’s risk of developing complications during pregnancy and childbirth is closely related to her overall health status, even before she conceives.

Risks increase when women conceive too early (adolescent pregnancy) and too often (insufficient birth-spacing). In addition, risks increase when a woman is malnourished in either macronutrients or micronutrients, such as iron and iodine. Avoiding death during childbirth also requires constant prenatal monitoring for complications, timely inoculations (particularly tetanus), and access to safe-delivery technologies that minimize the risk of infection. In other words, women need a combination of expensive preventative and curative health-care interventions at a time in life when they are at their least mobile and most vulnerable. Walking to a clinic for a preventive check-up is an onerous task for rural women who lack independent access to transportation, for displaced women contained in refugee camps, and for adolescents in societies where bearing a child out of wedlock is socially unacceptable.

If we examine maternal and child-health programs in countries that have managed to significantly reduce maternal mortality in the last 25 years, it is clear that they often invested in strong health-care delivery systems, which provide reliable services to women at low direct and indirect costs. Rather than focusing solely on curative healthcare, countries with such programs delivered easily accessible preventive healthcare, invested in family-planning, and relied on strong levels of community support and participation,

Rwanda for example, invested significantly in recruiting, training, and empowering women health care workers after the genocide that claimed 1 million lives, left 2 million displaced, and destroyed health systems almost completely. The government also decentralized the health sector to strengthen community involvement and trained 45,000 community health workers to provide primary health services at a village level. By 2012, Rwanda had one doctor per 16,000 people and one nurse per 1,300 people — a considerable increase from previous levels, especially considering that health-care delivery had ceased during the period of conflict. The government also established new standards for quality of care, including mandatory tetanus vaccination for pregnant women. By 2012, more than 69 percent of Rwandan women were giving birth in the presence of a skilled provider. Modern contraceptive prevalence increased in Rwanda from 4 percent to 45 percent in 10 years. In these indicators, Rwanda has surpassed wealthier counterparts like India and Nigeria.

A similar example comes from Iran, another country that achieved MDG target 5A on schedule. Iran achieved one of the most successful family planning programs in history, with a 40 percent decline in the total fertility rate (TFR) between 1986 and 2010 – from 3.2 to 1.8 children per woman. This was largely achieved through strong leadership by political and religious leaders who stressed the importance of lower fertility rates and investments in good healthcare services. Iran invested massively in community health: by 1998, 85 percent of the Iranian population had access to more than 15,000 “health houses,” staffed with male and female health workers who monitored family health in the surrounding areas. Workers, who were equipped with vehicles, provided necessary care to women in their homes. The government also trained over 5,000 rural midwives and recruited “Women Health Volunteers” throughout the country to provide education and preventive health services to women. While no single factor in this mix of policy interventions directly sought to lower the MMR, all of these efforts contributed to the MMR reduction.

Managing maternal health and lowering maternal mortality is also a challenge in the developed world. According to estimates from the Center for Disease Control, pregnancy-related deaths in the U.S. have risen from 7.2 per 100,000 live births in 1987 to 17.8 in both 2009 and 2011. This makes the U.S. one of the worst-performing wealthy countries and one of a handful of countries in the world with a worsening MMR. The cause of this increase in the MMR is largely unknown. Changes in the methods of gathering data (like moving from information on death certificates to survey data) may explain some of the increase. Additional causes may include the high direct and indirect costs of providing preventive care to socially excluded groups, a rise in obesity, late childbearing by some groups of the population, and the persistence of high levels of adolescent pregnancy rates.

Attaining the ambitious SDG target and reducing MMR to 70 deaths per 100,000 births will not be quick or easy. It will require that countries make significant investments in building health care systems, improving nutrition and access to preventive health measures for girls (including contraception), and increasing participation from communities. The examples of Rwanda and Iran illustrate that this is possible, even in some of the most unexpected places. The investment in maternal health is well worth the cost— not just for women, but for their children, families, communities, and the wider world.