Maternal Mortality: We Already Know What Works…Or Do We?

This is a joint post with April Harding.In a recent pitch for the $63 billion Global Health Initiative (see my post on the event), U.S. Secretary of State Hillary Clinton responded to a question about measuring progress in women’s health. “We are focusing on maternal mortality because that is so measurable. We know where we have a better idea of what works and what it will take to have more women deliver babies successfully. There’s all kinds of interventions from the very simplest, like a safe birthing kit, which is a piece of twine and a clean razor blade and a bar of soap and a piece of plastic to put under the women, all the way up to tertiary care for complicated pregnancies…”Is this true? What do we (the global health community) know? What more do we have to learn?Secretary Clinton is right, almost. We know that certain patient interventions can save women’s lives. For example, attendant-supervised deliveries and emergency interventions to address obstetric complications like hemorrhage, obstructed delivery etc. reduce delivery-related deaths.What we don’t know, unfortunately, is which programs or service delivery strategies will get these interventions to the women who need them, especially in weak health systems where most avoidable maternal deaths take place.What Has Worked? Why?Maternal mortality rates are falling in some countries, as documented in a recent study by Hogan et al. 2010. The analysis shows that over an 18 year period (1990-2008), countries including Egypt, Romania, Bangladesh, India and China had substantial success in reducing maternal mortality. However, only a few case studies have documented program strategies, let alone evaluated the outcomes. Evidence from Sri Lanka shows that long-term government commitment to broad, systematic improvements of health services for pregnant women can have a dramatic affect on maternal mortality rates, but we don’t know how to apply these insights to other health systems contexts.As I wrote in an earlier blog post:

We are just beginning to learn more about the effects of contraceptive use on the number of maternal deaths (fertility decline has a lot to do with reducing a woman’s risk of dying during pregnancy because it reduces the frequency of her “exposure” to pregnancy). We also know that while proven technologies needed to prevent most of the [350,000-500,000] maternal deaths that occur every year already exist (a fact which has prompted the WHO to designate such deaths as “avoidable”) we have almost NO evidence (see here for a succinct summary of the empirical evidence or lack thereof of interventions including traditional birth attendant training, increased skilled attendance at birth, antenatal care, community mobilization, and dissemination of clean delivery kits) from developing countries to support the claim that any single intervention can effectively reduce maternal mortality.

We don’t know which program strategies will work in developing countries to achieve sizable increases in access to and use of these services or “service delivery interventions.” This lack of knowledge has undermined most health programs (as April Harding discusses in the forthcoming 2011 CGD book “Private Patients: Why Health Aid Fails to Reach So Many, and What We Can Do About It”). For instance, unsuccessful service delivery strategies may be to blame for the failure of the Integrated Management of Childhood Illness approach, the standard program used to reduce child mortality for the past 15 years. (Victora et al 2006) Maternal health programs have had similar difficulties finding service delivery strategies which improve coverage of the patient interventions which will save women. (Hill et al 2007)What doesn’t work is equally important. At the recent Global Health Maternal Conference in New Delhi, Wendy Graham made a plea to the global health community to not only learn from successes but also from failures. We have limited resources—both donor and domestic—and to use these well, we need to learn how to make the best investments. Policies—donor and government—that drive the allocation of these limited resources need to keep up with technical know-how AND with the challenges of delivering these technologies in different contexts.The Long Road from Effective Patient Interventions to Saving LivesWithin the global health policy stratosphere, focus is often on mobilizing resources and making commitments to solve global health challenges in the developing world. While this focus is understandable and commendable, we must also talk about how to connect that money and policy productively to implementation. Unless we recognize the big problems in devising successful strategies to deliver services in a specific developing country context, we will certainly not solve these pressing global health challenges.The big push (money and policy) on maternal and child health at the global policy level is very welcome. But connecting these global resources to implementation for impact (read: fewer and fewer women and children die due to pregnancy and childbirth related causes) is critical. How will these new initiatives do better than previous ones in reaching the people they are trying to help? Interventions, no matter how effective, will not help people they cannot reach. The imminent MDG Summit 2010 is an opportunity for world leaders to commit to saving more women’s lives, especially when we know we can do it.