Pregnancy and childbirth claim the lives of more than half a million women around the globe each year. This translates to one woman dying every minute. The overwhelming majority of these deaths occur in the developing world. However, this does not mean that developing countries does not experience the same problem. They do! Nonetheless, nearly all of them could be prevented. Maternal mortality affects not only women, but also their families and communities. The risk of an infant dying increases significantly with the mother’s death. The death of a woman of reproductive age also brings significant economic losses and setbacks to community development. From human rights, economic, pharmacies ( c’est ici ) and public health perspectives, mobilizing resources to combat maternal mortality is imperative.

The slow success in reducing maternal mortality rates is due, in part, to the complex political and social issues related to poverty and the status of women. It is also due, in part, to the original misguided emphasis of maternal mortality programs in the developing world. The historical focus of these programs on the prediction and prevention of obstetric complications failed to take into account the scientific limitations of this approach. It also shifted the focus away from the critical period of delivery. Maternal morbidity, or complications experienced by women who survive childbirth, are also of great concern. For every woman who dies as a result of pregnancy, some 30 women live but experience lasting morbidities as a result. An estimated 20 million women suffer from nonfatal complications of pregnancy, including anaemia, infertility, pelvic pain, incontinence and obstetric fistula.

The Five Primary Complications

Nearly two thirds of maternal deaths worldwide are due to five direct causes: haemorrhage, obstructed labour, eclampsia (pregnancy-induced hypertension), sepsis, and unsafe abortion. The remaining third are due to indirect causes, or an existing medical condition that is worsened by pregnancy or delivery (such as malaria, anaemia, hepatitis, or increasingly, AIDS). About 15 per cent of all pregnancies will result in complications. Untreated, many of these complications will be fatal. What makes maternal mortality such a challenge is the fact that these complications are extremely difficult to predict. Despite years of research, we still have no reliable method of predicting the vast majority of cases of haemorrhage, obstructed labour and eclampsia.

While the general health status of pregnant women is important for a positive outcome of delivery, deadly complications randomly occur in all women. This is the case even in the developed world where the latest medical technology is readily available. Prediction is generally limited to identifying only high-risk groups of women. It is nearly impossible to determine which individual women will develop complications. In reality the overwhelming majority of pregnancies and births take place among women who are considered low risk. Consequently, while the percentage of deaths may be higher among high-risk women, the greatest numbers of deaths take place among women considered to be low-risk. For this reason, the focus for addressing maternal mortality has shifted from predicting complications during pregnancy to preparing for efficient emergency interventions. In general, emergency obstetric interventions are inexpensive and can easily be carried out by specially trained health professionals.

HIV/AIDS and Maternal Mortality

The exact percentage of maternal deaths linked to HIV and AIDS is unknown. HIV is associated with poor general maternal health, which makes women more vulnerable to a number of infections and conditions that increase the likelihood of complicated pregnancy outcomes, such as malaria, anemia and tuberculosis. HIV infection has also been associated with an increased risk of spontaneous abortion and of postpartum hemorrhage. Attributable risks have not yet been determined. HIV prevention and treatment and maternal mortality reduction are well-suited for joint programming, as there is considerable overlap in their causes and in the interventions to prevent them.

Sharing resources for HIV and maternal mortality prevention programming is logical. Programs that target the reduction of sexually transmitted infections reduce both the incidence of HIV infection and a woman’s risk of postpartum infection. Antenatal clinics are excellent places to offer voluntary testing and counseling for HIV, which can help women who are HIV negative get the information and skills to protect themselves from becoming infected. In addition, most maternal-to-child transmission of HIV occurs during delivery. Cesarean sections have been shown to reduce vertical transmission, the leading cause of HIV infection in children.

The Three Delays Model and its impact on mortality at childbirth

This is a framework to explain the social factors responsible for maternal death. It helps us target interventions and prevent maternal mortality at every stage. In most instances, women who die in childbirth experienced at least one of the following three delays: The First Delay is the delay in deciding to seek care for an obstetric complication. This may occur for several reasons, including late recognition that there is a problem, fear of the hospital or of the costs that will be incurred there, or the lack of an available decision maker. The Second Delay occurs after the decision to seek care has been made. This is a delay in actually reaching the care facility and is usually caused by difficulty in transport. Many villages have very limited transportation options and poor roads. Some communities have developed innovative ways to address this problem, including prepayment schemes, community transportation funds and a strengthening of links between community practitioners and the formal health system.

The Third Delay is the delay in obtaining care at the facility. This is one of the most tragic issues in maternal mortality. Often women will wait for many hours at the referral centre because of poor staffing, prepayment policies, or difficulties in obtaining blood supplies, equipment or an operating theatre. The third delay is the area that many planners feel is easiest to correct. Once a woman has actually reached an Emergency Obstetric Care facility, many economic and sociocultural barriers have already been overcome. Focusing on improving services in the existing centres is a major component in promoting access to Emergency Obstetric Care. Programs designed to address the first two delays are of no use if the facilities themselves are inadequate.

The Role of Antenatal Care in Preventing Mortality at Childbirth

Antenatal visits present an opportunity to address the psychosocial and medical needs of pregnant women while acknowledging the context in which they live. These periodic health exams allow women to make contact with the healthcare system. Health promotion messages can be individualized during this time, and women can be screened for potential risk factors. Antenatal visits can provide essential services for all pregnant women, such as tetanus toxoid immunization, nutrition education and the distribution of iron and folic acid tablets. The WHO recommends four antenatal visits. However, it is the quality of the visits rather than the number of visits that is of primary concern. Antenatal care is also an opportunity to offer voluntary counselling and testing for syphilis and HIV without a separate clinic visit. Pregnant women known to be seropositive can be started on a regimen of drugs designed to minimize vertical transmission. Antenatal visits also offer an opportunity to identify HIV-negative women and provide them with the skills and knowledge to remain negative. More recently, antenatal care has begun to offer Intermittent Preventative Treatment for malaria.

This is important as malaria contributes to anaemia, a significant factor in maternal morbidity and mortality. The treatment usually consists of single dose chemoprophylaxis given to pregnant women at least once after quickening. This is combined with the provision of insecticide-treated bed nets to prevent malaria infection. Intermittent Preventative Treatment is a relatively new intervention, and has yet to be thoroughly evaluated.

Involving Traditional Birth Attendants to Reduce Mortality at Childbirth

While some small projects have had success in training traditional birth attendants (TBAs), evaluation results are more often mixed, showing no significant reduction in maternal morbidity or mortality. This is due, in part, to the lack of well-trained medical staff and functioning referral services to provide backup for the TBAs in the event of a life-threatening complication. Neither trained nor untrained traditional birth attendants have the skills to deal with life-threatening problems. The WHO’s focus has changed to making professional care more accessible. Professionals are defined as physicians, midwives or nurses with midwifery skills. More recent programs have sought to promote the role of TBAs as culturally sensitive liaisons between the health system and the community.

Medical procedures and administration of medications should be performed by skilled health professionals. In contrast, many midwives and physicians have no training in belief systems, communication and community organizing. This is where the TBA can be most effective. For these reasons, WHO no longer promotes the training of traditional birth attendants to recognize or treat complications related to pregnancy. The Fund supports a role for TBAs to bridge the gap between communities and trained health providers. Traditional birth attendants can encourage women to use family planning and antenatal services and can emphasize the need for women to get Emergency Obstetric Care at hospitals or other facilities should complications arise. The WHO also provides clean delivery kits that can be used by midwives, family members or even TBAs in emergency situations to minimize the risk of infection.

The Role of Maternity Waiting Homes

Maternity waiting homes are residential facilities where women defined as “high risk” can await their delivery and be transferred to a nearby medical service shortly before delivery or sooner, if complications arise. The goal is to minimize the delay in receiving care for an obstetric emergency by dramatically reducing the transit time. Little quantitative research has been conducted to prove the efficacy of maternity waiting homes. A significant problem is determining which women are actually at high-risk. In some studies, women who are undergoing their first pregnancy have shown the greatest benefit from maternity waiting homes. Additionally, the majority of complications occur in women with no apparent risk factors. In addition, the four-week stay recommended is a barrier to use for many women, although it may allow some to get needed rest after delivery. Some countries have now progressed from using medical definitions of “high risk pregnancy” toward a broader concept based on a combination of distance and socio-economic and medical risk factors. In any case, maternity waiting homes should not be a stand-alone intervention, but should link communities with the health system in a continuum of care.

Enhancing Skilled Attendance at Birth

Most obstetric complications occur at the time of labour and delivery. It takes a professional to swiftly recognise life-threatening complications and to intervene in time to save the mother’s life. As noted before, previous efforts to promote skilled attendance at birth centred on the promotion of traditional birth attendants. A paradigm shift has taken place over the past decade to focus interventions on promoting an increase in professional attendance at delivery. It has been estimated that if 15 per cent of births are attended by doctors ( dentiste de garde ) and 85 per cent of them are attended by midwives, then maternal mortality will be adequately reduced. This ratio is most effective in situations where midwives attend normal deliveries and are able to effectively refer the 15 per cent of deliveries that result in complications to physicians. Skilled attendance at birth has been one of the most obvious common programming techniques in countries that have been successful in reducing maternal mortality.

Improved access to trained midwives who are supported by the broader health-care system is critical. Adequate support to midwives includes regular and reliable access to medications and supplies, and the respect and authority to make referrals to a higher level of care. In spite of overwhelming evidence that the use of doctors, midwives and nurses in deliveries is a crucial factor in reducing maternal mortality, only 58 per cent of all deliveries take place in the presence of a skilled attendant. There are many reasons for this. One is simply a shortage of professionally trained and skilled attendants. Another factor is a poor geographic distribution of attendants, with most professionals preferring to remain in urban areas. The WHO is seeking to address this problem by promoting more training of professionals, and by seeking innovative ways to retain them in the regions of greatest need. This includes providing incentives like housing and distance learning programs to midwives and doctors working in rural and semi-rural areas, and promoting rotation systems with a mix of public and private practice. Telemedicine the use of new technologies to link clinics or diagnostic images to centrally based professionals offers considerable promise for reaching out to women in rural or hard-to reach areas.