53648 Maternal Mortality at a glance I Why address maternal mortality? Reducing the number of orphans, who may have lower educational attainment and drastically Over 529,000 women die annually from diminished prospects of leading productive lives. complications during pregnancy, childbirth, or the I Reducing newborn mortality, thereby improving postpartum period. Nearly all of these deaths occur in developing countries, where fertility rates are child survival. higher and a woman's life time risk of dying during I Affirms the value of women in society, leading to pregnancy and childbirth is over 400 times higher more equitable opportunities for all. than in developed countries. Additionally, an I Providing opportunities to integrate HIV estimated 20 million women endure lifelong disabilities such as pelvic pain, incontinence, prevention, treatment, and care activities in obstetric fistula, anemia and infertility. The main maternal and child health (MCH) and family direct causes of maternal death are severe bleeding, planning (FP) programs to curb the HIV epidemic unsafe abortion, infection, eclampsia, and obstructed and mother to child transmission of HIV/AIDS. labor; the indirect causes include anemia, malaria, I The integration of prevention and treatment of heart disease, and HIV. Pregnancy complications are malaria in MCH services, resulting in better the main cause of death for women aged 15-19. pregnancy outcomes. High maternal mortality rates in many countries result I Strengthening the capacity of the health system, from poor reproductive health care, including not having access to skilled care during pregnancy and since many of the investments necessary for the childbirth and access to safe abortion even where it provision of maternity care (improving human is legal, especially for the poorest women. Risks of resources, upgrading infrastructure, strengthening poor outcomes during pregnancy and childbirth are logistics systems for supplies and equipment, etc.) exacerbated by poverty, low status of women, lack of benefit other health service components as well. education, poor nutrition, heavy workloads and I The unique opportunity towards achievements of violence. MDGs 4, 5 and 6. While many factors contribute to maternal death, one of the most effective means of preventing maternal Cost of maternal health care health is to improve health systems and primary health care to ensure availability of skilled attendance Providing basic maternal and newborn health at all levels and access to 24-hour emergency services ­ health care during pregnancy, delivery and obstetric care. Family planning services could also after birth, post-partum family planning, and newborn reduce maternal deaths and morbidities by 30 care ­ costs about US$3 per capita per year in a low percent. Prevention of unwanted pregnancies and income-setting; and about US$6 in a middle-income access to safe abortion as allowed by law and post- setting. The total cost of saving a mother's or infant's abortion care services could reduce maternal deaths life when complications arise is about US$230 per and injuries caused by unsafe abortions ­ over woman served in a low-income setting if surgery and 68,000 women die from unsafe abortions annually. hospitalization are required. Reducing maternal deaths and Millennium Development Goals improving maternal health provide The fifth Millennium Development Goal (MDG) to many benefits, including: which the international community, including the World Bank, has committed itself calls for the I Improving labor supply and productive capacity in reduction of maternal mortality ratios by three quarters women of reproductive age, resulting in improved between 1990 and 2015. The World Bank estimates household income and economic well-being of that only one developing region (Middle East and families and communities. North Africa) is on track to achieve this target. May 2006 The main interventions to improve referral, and transport are essential to averting the risks of maternal mortality. Families and communities need to be maternal health: able to recognize complications and be motivated to take I Ensure skilled attendance at delivery and improve action when a mother or child is in danger. health systems to increase availability and accessibility 2. Encourage delayed marriage and first birth for of emergency obstetric care adolescents. I Encourage delayed marriage and first birth for adolescents Girls aged 15-19 are twice as likely to die from I Address unwanted and poorly timed pregnancies childbirth as women in their twenties; those below the age of 15 are five times as likely. Reflecting both the I Improve coverage and quality of prenatal and frequency of early pregnancy and the risks associated postpartum care with it, pregnancy-related complications are the main I Promote cross-sectoral linkages that cause of death for girls aged 15-19 worldwide. Ensure secondary school education for girls and discourage · Promote enabling policies and political commitment early marriage by setting a minimum legal age of · Enhance community participation marriage of at least 18 for girls. First births can be · Address contextual factors (poverty, access to delayed by postponing the onset of sexual activity and economic resources, women's education and status, by using effective methods of fertility regulation. Efforts lack of male involvement, violence against women, should focus on changing individual and societal and the special needs of adolescents) motivations for early childbearing. Education and employment opportunities play a critical role in providing alternatives to early motherhood. How to reduce maternal mortality 3. Address unwanted and poorly timed pregnancies and 1. Ensure skilled attendance at delivery and strengthen the health risks associated with them. health systems to ensure 24 hour emergency obstetric care. Access to voluntary, safe, affordable, and appropriate family planning information and services is critical to Since much of maternal health care depends on skilled reducing unwanted pregnancies and to reducing the risks attendance, long-term strategic resource planning cannot of maternal mortality. Include an appropriate array of be emphasized enough. Skilled care or attendance refers high quality, consumer-oriented family planning to the process by which a pregnant woman and her information, counseling, and services in benefits/service infant are provided with adequate care during packages offered by public and private providers, and pregnancy, labor, birth, and the postpartum and extend these services to hard-to-reach groups (youths, immediate newborn periods, whether the place of poor rural and urban people) through outreach and social delivery is the home, health center, or hospital. In order marketing programs. For women who resort to abortion for this process to take place, the attendant must have the to end an unwanted pregnancy, it is important that necessary skills and must be supported by an enabling abortion services are safe when allowed by law and also environment at various levels of the health system. that post-abortion services are provided, including Three delays need to be considered systematically to guidance on contraceptive methods to avoid future address obstetric care: 1) delay in deciding to seek care; unwanted pregnancies. Compared with women who give 2) delay in identifying and reaching medical facility; and birth at 9- to 14-month intervals, women who have their 3) delay in receiving adequate and appropriate treatment babies at 27- to 32-month birth intervals are 2.5 times at the medical facility. WHO and UNICEF recommend more likely to survive childbirth. Ensuring birth intervals of one comprehensive and four basic essential obstetric care at least 24 months is best for maternal survival and (EOC) facilities for every 500,000 population. health. Considering access barriers such as a lack of roads and 4. Improve coverage and quality of prenatal and transport, the time taken to reach a facility would be a postpartum care. better indicator of physical access than population per facility. Facilities beyond public hospitals and clinics ­ The World Health Organization has developed clear such as birthing homes, private providers, and maternity practice guides on maternal and newborn care that can waiting centers ­ improve access to EOC for populations reduce the health risks of and provide quality services residing in remote and rural areas. Functioning health during pregnancy, delivery and the postpartum/postnatal systems with an enabling environment that ensures period. Prenatal care which includes prevention and/or adequate supplies, equipment, and infrastructure as well timely treatment for anemia, malaria, HIV, high blood as an efficient and effective system of communication, pressure and other complications is very cost-effective. What can be done to address maternal mortality? Cost-effective and feasible interventions with their intended beneficiaries and indicators. Beneficiaries/ Objectives Core Interventions Target Groups Indicators Ensure skilled attendance at delivery and strengthen health systems to ensure 24 hour emergency obstetric care* Reduce delays in recognizing Ensure skilled attendance at home and in facilities. Pregnant women and Maternal mortality ratio and managing complications Ensure prompt detection, management, and referral their infants % of deliveries with skilled attendance of pregnancy and delivery of complications. Case fatality ratio for complications Stress life-saving skills. Improve the capacity of the Train staff in midwifery skills at all levels of the Pregnant women and % of pregnant women receiving antenatal care at health system to provide health system. their infants least once quality maternal-newborn Improve quality of antenatal, delivery, postpartum & % of pregnant women who are anemic care including emergency newborn care through competency-based training Number and distribution of basic and care and supervision. comprehensive essential obstetric care Promote skilled attendance at home and in facilities. facilities/500,000 pop. Increase access to quality emergency obstetrics and newborn care. Improve referral system. Increase number of birthing homes and private providers. Provide public funds to finance transport and care for the poor. Reduce health risks of early, unwanted, and poorly-timed pregnancies Reduce early pregnancies Encourage delayed marriage; set a minimum legal Adolescent girls Age at marriage age of marriage of at least 18 for girls. Age at first birth Ensure community participation. Age at onset of sexual activity Reduce unplanned and Expand family planning services through community- Men and women of Total fertility rate poorly-timed pregnancies based workers, social marketing and health facilities. reproductive age, with Contraceptive prevalence rate Promote birth intervals of at least 24 months. special attention to Unmet need for spacing and limiting births (DHS adolescents, poor rural data) and urban people Age at first birth Reduce the risk of unsafe Provide post-abortion care and family planning Pregnant women, % of gynecological admissions that are for abortion information and services everywhere. especially adolescents abortion-related complications Ensure safety of abortion where not against law. Case fatality rate for abortion complications * For more information, please see RH Indicators Summary Sheet at http://www.worldbank.org/population. Beneficiaries/ Objectives Core Interventions Target Groups Indicators Improve coverage and quality of prenatal and postpartum care Detect and treat Ensure adequate prenatal care to prevent and/or Pregnant women and Maternal mortality ratio complications early in treat anemia, malaria, HIV, high blood pressure and their infants % of pregnant women receiving antenatal care at pregnancy other complications. least once Ensure early antenatal contact for care, counseling, % of pregnant women who are anemic and birth planning. Ensure community participation. Improve quality of antenatal, delivery, postpartum & Pregnant women and % of pregnant women receiving antenatal care at newborn care through competency-based training their infants least once and supervision. % of pregnant women who are anemic Build strong political commitment and enabling policies to ensure equal rights for women, and promote cross sectoral linkages Reduce incidence of FGM Work with community groups to find alternative Adolescent girls % of women reporting they have undergone rituals for initiation and/or alternative employment FGM (incidence rather than prevalence) for individuals who perform FGM. % of women experiencing FGM-related Target national and community leaders where complications of pregnancy and delivery performed. Reduce violence against Improve education of men and women about laws All women Frequency of violence women and educate about effects of violence on women and Violence during pregnancy society. Incidence of rape Support involvement of women's groups. Violent death rate among women Create an enabling Improve education and nutrition for girls. Women, particularly Ratio of girls to boys in primary, secondary, and environment for Provide credit and better employment opportunities adolescents tertiary education improvements in maternal for women. Ratio of literate women to men, 15-24 years old health outcomes Improve health communications capacity. Literacy and educational attainment Support involvement of women's groups and men in Spousal age and education differences reproductive health and rights. Employment and occupation Implement poverty reduction strategy. Share of women in wage employment in the non- agricultural sector Control of own earnings Women's participation in household decisions Proportion of seats held by women in national parliament Stunting among girls 5. Build strong political commitment and enabling DO plan for the long term to reduce maternal mortality. policies to ensure equal rights for women, and promote Long-term efforts are required to improve health systems cross sectoral linkages. and to professionalize delivery care. These include reducing poverty; improving women's DO aim to reduce violence against women. This is one education and nutritional status; improving water and example of putting women's rights in focus, and an sanitation, roads and infrastructure, and transportation; effective way of mobilizing society's resources to improve empowering women; and addressing traditional harmful MNH outcomes. practices such as female genital mutilation. The design of interventions needs to take account of forces outside the DO invest in women's reproductive health early in the life formal health system that are associated with maternal cycle. mortality risks. Domestic violence also contributes to poor By treating protein-energy and iron/folate and other maternal health outcomes. Providers need to be trained micronutrient deficiency in adolescents, young women to recognize the signs of violence, to use appropriate will better tolerate the increased demands of pregnancy, approaches for treatment and counseling, and to involve birth and lactation. The chances for a normal birth, communities. Promoting community involvement and resulting in normal birth weight and optimal growth and participation increases awareness of pregnancy development of the baby are strengthened. complications and support for seeking care. DO encourage male involvement for better promotion of Do's and Don'ts responsible sexuality. Men and women need equal access to information, DO pay attention to demand and access. education and services. Investments in health education and communication can increase demand for Maternal and Newborn health DON'T assume that improved performance has to cost a (MNH) care. Improvements in women's status through lot. education and economic opportunity have a strong Many countries have achieved better MNH outcomes by influence on demand for MNH services, including using their existing resources more effectively by building delivery of care. strong political and grassroots support for improved MNH outcomes. Do pay attention to increasing access to disadvantaged and hard to reach groups, including poor women and DON'T neglect behavior change. underserved areas. This is required for individuals, families, communities and An effective way to serve the needs of high risk groups providers if MNH outcomes are to improve. Effective and the poor is to involve community groups and NGOs health promotion and communications have contributed and pro-poor policy. to better MNH outcomes by reducing risky practices (unprotected sex), promoting positive ones (better DO pay attention to client perspectives and quality. hygiene and nutrition), and making providers more Programs that pay attention to consumers work better than attentive to the needs of their clients. those that impose top-down. Incentives that promote positive provider attitudes and behavior are more effective than targets and punitive management practices. Resources Managing Newborn Problems: A guide for doctors, nurses and midwives (2003) Lissner, C. and E. Weissman. 1998. "How much does Beyond the Numbers: Reviewing maternal deaths and safe motherhood cost?" World Health 51(1):10­11. complications to make pregnancy safer (2004) Lule et al. 2005. "Achieving the Millennium Development Making Pregnancy Safer - Essential health technology Goal of Improving Maternal Health: Determinants, package for costing maternal and newborn health Interventions, and Challenges." Health, Nutrition and intervention Population Discussion Paper Series, Human Development Network, World Bank, Washington, DC. ...plus other Integrated Management of Pregnancy and Childbirth (IMPAC) technical, managerial and program Setty-Venugopal, V. and U.D. Upadhyay. 2002. Birth tools and guidelines Spacing: Three to Five Saves Lives. Population Reports, Series L, No. 13. Baltimore, Population Information Program, Johns Hopkins Bloomberg School of Public Health. Useful Websites UNFPA. 2003. Mortality Update 2002. New York: UNFPA. http://www.worldbank.org/population UNFPA. 1997. The State of World Population 1997 -- http://www.safemotherhood.org/ The Right to Choose: Reproductive Rights and Reproductive Health. New York: UNFPA. http://www.who.int/making_pregnancy_safer/en/ World Bank and IMF. 2005. Global Monitoring Report: http://www.who.int/reproductive- The Millennium Development Goals: From Consensus to health/MNBH/index.htm Momentum. Washington, DC: World Bank. http://www.unfpa.org/icpd/ WHO, UNICEF and UNFPA. 2003. Maternal Mortality http://www.rho.org/html/safe_motherhood.htm in 2000: Estimates Developed by WHO, UNICEF and UNFPA. Geneva: WHO. http://www.safemotherhood.org/facts_and_figures/good _maternal_health.htm WHO. 1997. Mother-Baby Package Costing Spreadsheet. Geneva: WHO. http://www.who.int/mediacentre/news/releases/2003/ pr93/en/index.html WHO. 2004. Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2000. Geneva: WHO. For more information Making Pregnancy Safer, WHO: World Bank: Rama Lakshminarayanan (rlakshminarayana@worldbank.org), Rifat Hasan Pregnancy, Childbirth, Postpartum and Newborn care: (rhasan@worldbank.org), and for Africa, Elizabeth Lule A guide for essential practices (2003) (elule@worldbank.org), Khama Rogo Managing Complications in Pregnancy and Childbirth: (krogo@worldbank.org) A guide for Midwifes and Doctors (2000) WHO Department of Making Pregnancy Safer: Monir Islam (islamm@who.int) Expanded versions of the "at a glance" series, with links to resources and more information, are available on the World Bank Health, Nutrition and Population web site: www.worldbank.org/hnp