|DR. J. E. PARK MEMORIAL ORATION
|Year : 2012 | Volume
| Issue : 3 | Page : 196-203
Public health approach to address maternal mortality
Sanjay K Rai1, K Anand1, Puneet Misra1, Shashi Kant2, Ravi Prakash Upadhyay3
1 Additional Professor, Centre for Community Medicine, AIIMS, New Delhi, India
2 Professor, Centre for Community Medicine, AIIMS, New Delhi, India
3 Senior Resident, Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
|Date of Web Publication||3-Dec-2012|
Sanjay K Rai
Additional Professor, Centre for Community Medicine, Old OT Block, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 29
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Reducing maternal mortality is one of the major challenges to health systems worldwide, more so in developing countries that account for nearly 99% of these maternal deaths. Lack of a standard method for reporting of maternal death poses a major hurdle in making global comparisons. Currently much of the focus is on documenting the "number" of maternal deaths and delineating the "medical causes" behind these deaths. There is a need to acknowledge the social correlates of maternal deaths as well. Investigating and in-depth understanding of each maternal death can provide indications on practical ways of addressing the problem. Death of a mother has serious implications for the child as well as other family members and to prevent the same, a comprehensive approach is required. This could include providing essential maternal care, early management of complications and good quality intrapartum care through the involvement of skilled birth attendants. Ensuring the availability, affordability, and accessibility of quality maternal health services, including emergency obstetric care (EmOC) would prove pivotal in reducing the maternal deaths. To increase perceived seriousness of the community regarding maternal health, a well-structured awareness campaign is needed with importance be given to avoid adolescent pregnancy as well. Initiatives like Janani Surakhsha Yojna (JSY) that have the potential to improve maternal health needs to be strengthened. Quality assessments should form an essential part of all services that are directed toward improving maternal health. Further, emphasis needs to be given on research by involving multiple allied partners, with the aim to develop a prioritized, coordinated, and innovative research agenda for women's health.
Keywords: Maternal mortality ratio, Maternal mortality, Causes determinants, Public health approach
|How to cite this article:|
Rai SK, Anand K, Misra P, Kant S, Upadhyay RP. Public health approach to address maternal mortality. Indian J Public Health 2012;56:196-203
|How to cite this URL:|
Rai SK, Anand K, Misra P, Kant S, Upadhyay RP. Public health approach to address maternal mortality. Indian J Public Health [serial online] 2012 [cited 2019 Dec 14];56:196-203. Available from: http://www.ijph.in/text.asp?2012/56/3/196/104231
| Introduction|| |
Pregnancy and child birth is a normal physiological process and every pregnant woman hopes to give birth safely. Sadly, this is not what is actually happening. In 2010, nearly 287,000 maternal deaths occurred worldwide, down from 358,000 in 2008. , Developing countries accounted for nearly 99% of these deaths with Sub-Saharan Africa and South Asia contributing to 85% of the global maternal deaths.  The adult lifetime risk of maternal death, for the year 2010, was 1 in 39 for Sub-Saharan Africa and 1 in 160 for Southern Asia, whereas developed regions experienced a much smaller lifetime risk of 1 in 3800.  For the year 2010, the global maternal mortality ratio (MMR), that is, maternal deaths per 100,000 live births was estimated to be 210 (MMR for least developed countries - 430, developing countries - 240, and developed/industrialized region - 12).  Among the developing regions, Sub-Saharan Africa had the highest MMR at 500 maternal deaths per 100,000 live births, followed by South Asia (220), Oceania (200), and South-Eastern Asia (150).  Countries such as Afghanistan, Chad, Guinea-Bissau, and Somalia had an extremely high MMR of at least 1000. 
Thus, maternal mortality still remains a major challenge to health systems worldwide. This is reflected in Millennium Development Goals (MDGs). Improving maternal health (MDG-5) is one of the eight MDGs adopted by 189 counties in the world during millennium summit in 2000.  The targets for MDG-5 are to reduce the MMR by three quarter between 1990 and 2015, and to achieve universal access to reproductive health by 2015. 
| Indian Scenario|| |
Each year approximately 55,000 women die in India due to pregnancy or childbirth-related complications.  The MDGs of the United Nations has set the target of achieving 109 maternal deaths per 100,000 live births by 2015. , The MMR for India for the years 2007-2009 was 212 per 100,000 live births, down from 254 in 2004- 2006.  Trends in MMR for the last 10 years (1999- 2000 to 2007-2009) reveal that there has been a decline of 35%, that is, from 327 to 212 deaths per 100,000 live births on a national level with Empowered Action Group (EAG) states and Assam achieving a reduction of 33% (461 to 308) and southern states attaining a decline of 38% (206 to 127) [Figure 1]. It is worth noting that Kerala (81) along with Tamil Nadu (97) and Maharashtra (104) have already achieved MDG target in 2007-2009.  Andhra Pradesh (134), West Bengal (145), Gujarat (148), and Haryana (153) are in closer proximity to the MDG target.  However, despite this apparent progress, India is not on track to meet either its national or international targets. As per the MDG target, a 75% reduction in MMR from 1990 till 2015 would need a yearly rate of decline of 5.5%.  For India, the rate of reduction has been only 3.1%, that is, from 523 in 1990 to 212 maternal deaths per 100,000 live births in 2007-2009.
|Figure 1: Trends in maternal mortality ratio for India (1999– 2000 to 2007– 2009)*|
Click here to view
| Public Health Approach|| |
Public health approach to any problem consists of estimating the magnitude of problem, identifying its causes and determinants, identifying a set of individual and population-based interventions, operationalization, and its evaluation. ,, The same can be applied to maternal mortality as well. Maternal mortality is just one end of the spectrum and one must consider the disability adjusted life years (DALYs) due to pregnancy-related complications as well. Further, a maternal death results in a "motherless" family, which has very serious consequences for the children and other family members.
| Methods for Estimation of Maternal Deaths|| |
Surveillance is a key public health measure and provides reliable estimates that are crucial to monitor progress in terms of reducing the MMR and for the purpose of advocacy. Currently, no standard method is being adopted worldwide to document the burden of maternal deaths and this acts as a major hurdle in making global comparisons. Measuring maternal mortality accurately is usually difficult except where there is comprehensive registration of deaths and causes of death. There are only a few countries, mainly those that are developed, where such registration could be characterized as complete and even in these countries, poor attribution of cause of death results in significant underreporting of maternal deaths. ,,
Several alternative techniques have been developed to fill the gap caused by poorly functioning vital registration systems. These techniques include direct household survey method, sisterhood method, reproductive age mortality studies (RAMOS), verbal autopsy and census. Of these, the RAMOS is considered to be the gold standard for measuring maternal mortality because it involves identifying and investigating the causes of all deaths of women of reproductive age in a defined area/population by using multiple sources of data (e.g., interviews of family members, vital registrations, health facility records, burial records, traditional birth attendants (TBAs)). ,,,, If properly conducted, this approach provides a fairly complete estimation of maternal mortality (in the absence of reliable routine registration systems) and could provide estimates of sub-national MMRs as well.  However, this approach is complicated, time-consuming, and expensive to undertake, particularly on a large scale. Further, the number of live births used in the computation may not be accurate, especially in settings where most women deliver at home. 
Where vital registration data are not appropriate for the assessment of cause-specific mortality, the use of household surveys provides an alternative.  However, household surveys using direct estimation are expensive and complex to implement because large sample sizes are needed to provide a statistically reliable estimate.  Another approach currently used in most developing countries derives estimates of maternal mortality using the sisterhood method. ,,, The sisterhood method is a survey-based measurement technique that substantially reduces sample size requirements in high-fertility populations because it obtains information by interviewing respondents about the survival of all their adult sisters. , Although sample size requirements may be reduced, the problem of wide confidence intervals remains.  Furthermore, the method provides a retrospective rather than a current estimate. The overall estimate of maternal mortality is determined for 10-12 years before the survey. ,,
A national census, with the addition of a limited number of questions, could produce estimates of maternal mortality.  This approach eliminates sampling errors (because all women are covered) and hence allows trend analysis. , This approach also allows identification of deaths in the household in a relatively short reference period (1-2 years), thereby providing recent maternal mortality estimates, but is conducted at 10-year intervals and therefore limits monitoring of maternal mortality. , The training of enumerators is important, since census activities collect information on a range of other topics, which are unrelated to maternal deaths. 
| Identifying Causes and Determinants of Maternal Deaths|| |
Medical Causes of Maternal Deaths
Understanding the causes of maternal mortality is crucial in addressing the challenge of high rates of maternal mortality. Women usually die as a result of complications during and following pregnancy and childbirth. The complications that account for the majority of maternal deaths are hemorrhage (25%), infections (15%), unsafe abortion (13%), high blood pressure during pregnancy (preeclampsia and eclampsia) (12%), and obstructed labor (8%). ,, According to the analysis of causes of maternal deaths published in Lancet, hemorrhage was the leading cause of maternal deaths in Africa (33.9%) and Asia (30.8%).  In the developed countries, most deaths occurred due to complications of anesthesia and cesarean sections (21.3%).  Hypertensive disorders represented the cause of highest number of deaths in Latin America and the Caribbean (25.7%), whereas for Africa and Asia, it accounted for 9.1% of the maternal deaths each. HIV/AIDS was responsible for about 6% of deaths in Africa, whereas anemia (12.8%) and obstructed labor (9.4%) each caused about one-tenth of deaths in Asia. 
Ectopic pregnancy was recorded as the cause in less than 1% of deaths in developing countries and almost 5% in developed countries.  Compared with developed countries (2.1%), sepsis was significantly more frequent in Africa (9.7%), Asia (11.6%), and Latin America and the Caribbean (7.7%). Abortion-related deaths were comparatively higher in developed countries (8.2%) and in Latin America and the Caribbean (12%) compared with Africa (3.9%) and Asia (5.7%).  Lower contribution of abortion-related deaths to the overall cause-specific mortality figures in Africa and Asia could be due to under-reporting and misclassification.
Social Correlates of Maternal Deaths
Maternal mortality is considered to be a measure of women's status in the society, representing the accessibility of social supports, economic opportunities, and health care. , Background factors, such as age, parity, female literacy, socio-economic status, women empowerment, and availability, accessibility, and affordability of quality health care facilities, influence the outcome of maternal pregnancy in the developing world. ,,, Studies have shown that human development index (HDI) values, that encompass knowledge/education and standard of living, are strong predictors of maternal mortality.  The lower a country ranks in terms of human development, the higher the expected rate of maternal mortality.  Education gives women the knowledge to demand and seek proper health care.
Low status of women in the household and society as a whole, as exemplified by inequality in education, employment, property ownership, participation, and decision-making, is another important correlate. , Pregnancy outcome and maternal survival have strong correlations with household behavior and decision-making.  Cognizant communities value the health of the mothers and seek prompt attention at the earliest indication of problems. Harmful traditional practices and religious beliefs also adversely affect maternal health. ,,, The cost of accessing care, both direct and indirect, can be prohibitive in seeking care.  Poorly financed and unaccountable health systems, including weak referral systems, are one of the key determinants of maternal outcome. Another determinant is poor access to quality maternal health care services because of geographical terrain and poor roads. ,
Till now, much of the focus has been on documenting the "number" of maternal deaths and delineating the "medical causes" behind these deaths. The need of the hour is to look beyond merely the numbers. Emphasis is to be made on acquiring an in-depth understanding of whether the women are dying because they are unaware of the need for care/unaware of the warning signs of problems in pregnancy or the services do not exist/are inaccessible for other reasons such as distance, cost or socio-cultural barriers or the care they receive in traditional or modern health services is inadequate.  A clear cut understanding of these issues would help the health professionals, concerned authorities and policy makers to adopt a comprehensive approach. Answering such questions and taking actions to address any of these insufficiencies is presumably more important than simply estimating the magnitude of maternal deaths.
| Public Health Interventions|| |
- The first step for avoiding maternal deaths is to ensure that women have access to family planning and safe abortion. This will reduce unwanted pregnancies and unsafe abortions.
The women who continue pregnancies need care during this critical period for their health and for the health of the babies they are bearing. Essential maternal care, early management of complications and good quality intrapartum care form the mainstay. Providing essential evidence-based interventions, through focused antenatal care (ANC) are required. Requisite interventions in ANC include early registration of pregnancy, identification and management of obstetric complications, tetanus toxoid immunization along with identification, and prompt management of infections. , ANC is also an opportunity to promote the use of skilled attendance at birth, child care healthy behaviors and planning for optimal pregnancy spacing.
- Delivery by skilled birth attendants and provision of emergency obstetric care (EmOC) are important components of good intranatal care. As defined by the World Health Organization (WHO), a skilled birth attendant/personnel is an accredited health professional, such as a midwife, doctor or nurse, who has been trained for proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.  Skilled attendance at all births is considered to be a critical intervention for ensuring safe motherhood. This is why the proportion of births attended by a skilled health provider is one of the two indicators for measuring progress toward the MDG-5.  The skilled birth attendance rate for India for the year 2006-2010 was 53%, which does not seem to be satisfactory enough.  Besides this, it is not only important to increase the skilled attendance at birth but also to improve the quality of services provided by these skilled attendants.
- Up to 15% of all births are complicated by a potentially fatal condition.  Although many of these complications are unpredictable, almost all are treatable. Thus, in order to avert maternal deaths, the focus must also be placed on ensuring that women have access to quality EmOC. EmOC is the term used to describe the elements of obstetric care needed for the management of normal and complicated pregnancy, delivery and the postpartum period. Basic emergency obstetric care (EmOC) includes administration of antibiotics, oxytocics, anticonvulsants, manual removal of the placenta, removal of retained products, and assisted vaginal delivery with forceps or vacuum extractor. Comprehensive EmOC includes all basic EOC functions plus cesarean section and blood transfusion. EmOC includes in its purview, upgrading of peripheral facilities to provide basic and comprehensive obstetric care, training health staff to manage obstetric complications along with ensuring that a functioning referral system is in place, which links peripheral facilities to district health facilities or referral centers that can provide EmOC. Evidence to support the role of EmOC in reducing maternal mortality can be drawn from Bangladesh, Latin America, and Egypt. ,,
| Operational Issues|| |
Poor coverage of antenatal services is an issue of concern. In the developing world as a whole, three-quarters (77%) of pregnant women receive ANC from a skilled health provider at least once and 46% receive ANC for four or more visits, although information on the quality of the care lacks substantially.  In India, as per the National Family Health Survey (NFHS)-3, less than half (43%) of the women received ANC during the first trimester.  As per the Coverage Evaluation Survey (CES), United Nations Children's Fund (UNICEF) (2009), only 26.5% of the women during their last pregnancy had received full ANC, which includes at least three ANC visits, one tetanus toxoid, and ≥100 iron and folic acid tablets. 
The presence of skilled birth attendants is advocated as a measure to prevent maternal complications and deaths. The available statistics pose a none-too happy picture. In 2000-2007, skilled health workers attended an estimated 61% of the total number of births in the developing world.  The two regions with the lowest levels of skilled birth attendance for the year 2000-2007, that is, Sub-Saharan Africa (45%) and South Asia (41%) are also the regions with the highest incidence of maternal mortality. 
In India, although the number of deliveries attended by skilled personnel increased from 42% in 1998-1999 to 53% in 2008, yet it is unsatisfactory. , Moreover, as per NFHS-3, only 37% of mothers had a postnatal check-up within 2 days of birth, as is recommended and only 15% of home births were followed by a postnatal check-up.  The government of India had launched Janani Suraksha Yojna (JSY) in 2005 under the National Rural Health Mission (NRHM) with the objective of reducing the maternal and neonatal mortality by promoting institutional delivery. Although it would be too early to assess its impact on reducing MMR, the institutional delivery rates have gone high in most of the states.
A recent report evaluating the performance of NRHM in seven states of India, namely, Uttar Pradesh, Madhya Pradesh, Jharkhand, Odisha, Assam, Jammu and Kashmir, and Tamil Nadu found an increase in the institutional delivery in every state.  In Jharkhand, a state with relatively low figures of institutional deliveries and high maternal mortality, there has been an upsurge in the number of institutional deliveries from around 52,000 in 2005-2006 to 194,000 in 2008-2009.  The MMR have also gone down by nearly 16%, that is, from 312 in 2004-2006 to 261 in 2007-2009. , Thus, up-scaling of JSY could be seen as a way to improve maternal health, although certain issues need to be addressed, such as improving the quality of care provided, ensuring timely payment to the beneficiaries, strengthening the grievance management mechanism, and improving the monitoring and supervision process. 
An important issue with the coverage estimates for service delivery such as ANC, skilled attendant at birth and postnatal visits for the mother is that they do not address the quality of contact or the nature of interventions provided to the mother. Quality assessments should form an essential part of such services. Poor utilization of welfare schemes by pregnant women is also an issue that needs attention. For example, in India, the integrated child development services (ICDS) program provides nutrition and health services for pregnant women. These services are provided through community-based anganwadi centers (AWC). According to the NFHS-3 report, most pregnant women did not use the services provided. Only 21% of women had received supplementary food from an AWC during their last pregnancy, 12% received health check-ups, and 11% received health and nutrition education.  Efforts to increase awareness about such welfare schemes clubbed with improving the quality of services provided would go a long way in increasing the utilization of such services.
Another important issue relates to the problem of adolescent pregnancy. Globally, about 16 million adolescent girls aged 15-19 years give birth each year, which roughly accounts for 11% of all births worldwide.  Around 95% of these adolescent births occur in low- and middle-income countries.  Adolescents aged 15-19 years are twice as likely to die during pregnancy or child birth as those aged over 20 years, whereas girls aged under 15 years are five times more likely to die. , Further, each year, at least 2 million young women in developing countries undergo unsafe abortion.  Unsafe abortion can have devastating consequences, including cervical tear, uterine perforation, hemorrhage, chronic pelvic infection, infertility, and death. ,
Adolescent mothers often lack knowledge, education, and experience relative to older mothers. Keeping this in view, the programs should emphasize on approaches to overcome these relative disadvantages. Adolescent girls should be provided with vocational training and sex education to increase their autonomy, self-esteem, and decision-making abilities. Programs should be put in place to promote education and reduce drop outs from school. Pregnant adolescents, their families and the community need to be made aware of the knowledge about pregnancy-related complications and their associated signs/symptoms through, intensive information,education and communication (IEC) activities.
Another set of challenge exists in bringing the pregnant women and the health system closer to each other. There are broadly two ways of doing so; either bring the health system closer to the women or bring the women closer to the health system. In India, till recently, the first approach was adopted, that is, bringing the health system closer to the women, through training of TBAs and auxiliary nurse midwives (ANM), but these yielded limited results. Studies have shown that training of midwives and incorporating them in the health system does reduce maternal deaths but that holds true in countries where the MMR are very high, that is, in the range thousands. , In places where the ratio is in hundreds, adopting such an approach is unlikely to yield further reduction in MMR.
In India, for example, the current MMR is 212 per 100,000 live births and bringing it down by 103 points (in order to achieve the MDG goal) would possibly require the approach to bring the women to the health system through creating large-scale community awareness, health system strengthening, capacity building, formulating sound referral mechanisms, and research to understand the role of barriers and incentives in context to institutional delivery, rather than merely involving trained TBAs and ANMs. Although the government of India, under NRHM has launched a conditional cash transfer scheme called JSY with the objective to reduce maternal and neonatal mortality through institutional delivery, yet it would be too early to document its impact on reducing the MMR. The evaluation of JSY published in the Lancet by Lim et al. has suggested that the program is having a significant impact on perinatal and neonatal health.  Although it is likely that the similar results will be observed in terms of reducing maternal mortality, the authors avowed that it would be early to comment on its impact on maternal mortality.
| Conclusion|| |
There is a need to develop a standardized method of maternal mortality estimation. This will help in making international comparisons and also to conclusively monitor a country's progress toward the goal of reducing maternal deaths. Avoiding maternal deaths is possible, even in resource-poor countries, but it requires the right kind of information on which to base future programs. Merely knowing the magnitude of maternal mortality is not enough. We need to understand the underlying factors behind maternal deaths. Investigating and in-depth understanding of each maternal death can provide indications on practical ways of addressing the problem. To increase perceived seriousness of community regarding maternal health, a well-structured awareness campaign is needed with emphasis on avoiding adolescent pregnancy. Ensuring the availability, affordability and accessibility of quality maternal health services, including EmOC, is one of the key prerequisites for reducing the MMR. The delivery of interventions to women when and where they need them should be a purposeful policy of all countries. Further, emphasis needs to be given to research, through involving multiple allied partners, with the aim to develop a prioritized, coordinated, and innovative research agenda for women's health.
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