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Ending “Preventable” Maternal Deaths With Limited Resources: Learning From Successful Country Programs

By: Gold-Marie Wontumi, Public Health Practitioner

According to the World Health Organization, most maternal deaths are preventable. The concept of a preventable maternal death, however, is nuanced: A maternal death is more easily prevented in settings with access to health care providers, infrastructure and supplies compared to settings with limited resources.

The challenge of preventing “preventable” maternal deaths

In many low-resource settings, where the vast majority of maternal deaths occur, there is often a significant lack of infrastructure, supplies and equipment to manage complications. As a result, interventions to improve facilities’ capacity to respond quickly and effectively to obstetric emergencies are often extremely difficult to implement.

Two of the leading causes of maternal mortality—postpartum hemorrhage and pre-eclampsia/eclampsia—are preventable with timely, high quality emergency obstetric care. However, life-saving interventions for these complications, including blood transfusion and essential medicines, are often unavailable in facilities in low-income countries. Therefore, a maternal death that would be classified as preventable may seem unpreventable to a health care provider working in this context, which can result in frustration and a loss of motivation.

A number of challenges must be addressed in order to ensure that all women receive timely access to high quality emergency obstetric care, even in very low-resource settings. Several low- and middle-income countries have implemented effective interventions to reduce maternal deaths despite resource limitations and other challenges.

Improving emergency obstetric care

Ethiopia

Despite some progress, Ethiopia fell short of attaining the Millennium Development Goal (MDG) 5 target of reducing its maternal mortality ratio (MMR) by three quarters between 1990 and 2015. Between 2010 and 2013, a health system strengthening intervention aimed at addressing maternal mortality was implemented in three districts of the largely rural southwest region. Components of the program included enhancing the capacity of facilities to provide basic and emergency obstetric care, enhancing the quality of services and strengthening referral systems. In order to build capacity for providing basic and emergency obstetric care, the program prioritized infrastructure and equipment, health worker training and monitoring and supervision. The three-year program resulted in a 64% reduction in maternal mortality, largely due to increased availability and access to emergency obstetric care.

Nepal

Nepal reduced its maternal mortality rate substantially—from 850 deaths per 100,000 live births in 1991 to 170 deaths per 100,000 live births in 2011. Despite this progress, the government recognized a need for further reduction and developed a strategy to reduce inequities in emergency obstetric care through a “nationwide upgrade of lower level facilities.” The government of Nepal partnered with UNICEF to conduct a needs assessment focused on facilities’ capacity to deliver 24-hour and full week services. Based on the findings, new facilities were constructed and existing facilities were upgraded. With financial and technical support from UNICEF, Nepal increased the number of facilities providing basic emergency obstetric care from 18 facilities in five districts to 201 facilities in 11 districts, over a period of 5 years.

Rwanda

Rwanda has achieved remarkable declines in maternal mortality in recent decades. The government adapted the Rapid SMS-MCH system from a platform originally designed by UNICEF as part of efforts to use information technology to accelerate progress in maternal health. In 2010, the government of Rwanda, with support from UNICEF and other collaborators, established a partnership with a private mobile phone company to conduct a pilot intervention that involved real-time, two-way communication between community health workers (CHWs) and the health system. This mHealth program strengthened the communication and referral process in cases of obstetric emergencies to facilitate timely care. An evaluation found that 100% of CHWs complied with reporting requirements, and there was a 27% increase in facility-based births.

Lessons learned for reducing maternal mortality

Though countries have implemented diverse programs to reduce maternal deaths in low-resource settings, their approaches illustrate several common strategies and priorities:

– National government commitment
– Data-informed decision-making
– Innovation in health care financing
– Adoption of a health system strengthening framework
– Collaboration with related sectors such as transportation, education and water and sanitation

Leadership is key to implementing maternal health programs in all countries. The national maternal mortality target under the Sustainable Development Goal agenda is that every country reduces its MMR by at least two-thirds from its 2010 baseline level by 2030, and countries with very high MMRs will need to reduce even more. This target can only be accomplished with strong country leadership and government commitment to addressing maternal deaths.

Learn more about the global and national maternal mortality targets under the Sustainable Development Goals.

Check out the Maternal Health Task Force’s Obstetric Emergency Drills Training Kit.

Read the 2015 report from the World Health Organization, “Strategies toward ending preventable maternal mortality (EPMM).”

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