Between 1990 and 2015, the global maternal mortality ratio (MMR) decreased by 44% under the Millennium Development Goals (MDGs), from 385 to 216 maternal deaths per 100,000 live births. Despite this progress, we fell short of the MDG target of reducing the global MMR by 70%, and perhaps more importantly, huge inequalities persist both within and among countries. For example, as an aggregate figure, sub-Saharan Africa has by far the highest MMR at 546 maternal deaths per 100,000 live births while the average MMR in developed regions is just 12 maternal deaths per 100,000 live births. The devastating consequences of maternal deaths extend not just to families but entire communities.
The majority of maternal deaths are preventable: about three quarters of all maternal deaths are caused by postpartum hemorrhage, hypertensive disorders such as pre-eclampsia/eclampsia, infections, unsafe abortion and other delivery-related complications. Even if a woman manages to access prenatal care and deliver in a health facility with a skilled birth attendant, poor quality of care can be life-threatening. These immediate causes only paint part of the picture though; the risk factors for maternal death begin long before delivery. Social determinants such as place of residence, socioeconomic status and family dynamics as well as institutional factors such as national resource allocation, data infrastructure and political accountability for evidence-based programming influence a woman’s likelihood of dying from childbirth-related complications. Particular attention to family planning is warranted given that approximately 29% of maternal deaths could be averted through met need for contraceptives and another 13% through access to safe abortion.
Developing targets for ending preventable maternal mortality
Ending preventable maternal mortality (EPMM) is a priority under the Sustainable Development Goals (SDG) agenda. SDG 3.1 aims to reduce the average global MMR to less than 70 maternal deaths per 100,000 live births by 2030. The national targets from the World Health Organization (WHO) EPMM strategies report released in February 2015 specify that every country should reduce its national MMR by at least two-thirds from 2010 baseline levels, and no country should have an MMR greater than 140 maternal deaths per 100,000 live births. Achieving these targets will be a challenge, especially for countries with the highest MMRs. Thinking critically about how individual countries will achieve the SDG targets for maternal mortality is crucial. The 2015 EPMM strategies report priority recommendations call for an increased focus on data-driven programming based on an understanding of causes of death in each country, improved measurement and data quality to make this possible, integrated maternal and newborn care, equitable access to and quality of care, health systems strengthening and adherence to a human rights framework.
Monitoring progress in ending preventable maternal mortality
The EPMM working group has been in the process of developing a comprehensive monitoring framework to address these priorities in two phases. Phase I, which was completed in October 2015, identified a core set of proximal maternal health indicators for global monitoring and reporting by all countries to complement core metrics identified by the Every Newborn Action Plan. Together those indicators, which include adolescent birth rate, skilled attendance at birth, early postpartum care (within 2 days of birth), cesarean section rate, met need for family planning and availability of functional emergency obstetric and newborn care facilities among others, fed into the development of the Global Strategy Indicator Framework. The goal of Phase II, which is currently underway, is to develop indicators for the more distal social, political and economic determinants of maternal health and survival that are highlighted in the EPMM Strategies report. Phase II also includes a “means for implementation” for national and global stakeholders to track progress in these critical areas. The final set of EPMM Phase II indicators will be passed on to WHO’s recently-formed Mother Newborn Information for Tracking Outcomes and Results (MoNITOR) expert advisory group.
Having a global MMR target is not sufficient for ensuring high quality of maternal health care and equal access for all women across the globe. We need a consensus on a set of measures to drive improvements in the health system and to address the underlying social, political and economic factors that can make quality of care reliably available to all women in every setting. The widespread use of such indicators will allow researchers and policymakers to track progress over time and identify particularly vulnerable populations, specific areas for improvement and more effective intervention strategies to create pathways toward achieving the maternal newborn health targets of the SDGs by 2030.
Read the “Strategies Toward Ending Preventable Maternal Mortality (EPMM)” report.
Check out an interview with MHTF’s Rima Jolivet on the role of midwifery in ending preventable maternal mortality.
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