Eastern Mediterranean Health Journal
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Volume 11 No 4 May , 2005		Print this article	PDF

Reducing maternal mortality in the Eastern Mediterranean Region

R. Mahaini¹ and H. Mahmoud²

ABSTRACT: Current efforts in some countries of the Eastern Mediterranean Region are still insufficient to achieve the fifth Millennium Development Goal on improving maternal health. Strong commitment, intensive efforts and effective national policies and strategies are now urgently required in order to translate vision into action. Such efforts and plans should target the strengthening of health systems, the expansion in the coverage of effective integrated interventions, and the recognition of the essential role of individuals, families and communities in making pregnancy safer. This article provides a background on the current situation of maternal health in the Eastern Mediterranean Region, including underlying causes and contributing factors, and describes strategic directions aimed at accelerating the reduction of maternal mortality in the Region and moving closer to the achievement of the Millennium Development Goals. .

¹Coordinator, Family and Community Health; 2Medical Officer, Making Pregnancy Safer, Division of Health Promotion and Protection, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to R. Mahaini: mahainir@emro.who.int).

 

Introduction

Globally, progress towards reducing maternal mortality has been so far slow and insufficient. More than half a million women around the world die each year as a result of pregnancy and childbirth. Millions more become ill or are left disabled. In addition, each year, 3.3 million babies are dead at birth and another 4 million do not survive beyond the first 4 weeks of life; many more are left handicapped because of inadequately managed pregnancies and births. The vast majority (99%) of maternal deaths take place in developing countries. In the Eastern Mediterranean Region alone, around 53 000 women of childbearing age die every year as a result of pregnancy-related complications.
Most maternal deaths arise from complications during childbirth, in the immediate postpartum period, or as a result of unsafe abortion. Factors commonly associated with these deaths include the absence of skilled health personnel during pregnancy and childbirth, lack of services able to provide emergency obstetric care and deal with the complications of unsafe abortion, and ineffective referral systems. Most of these maternal deaths are considered potentially preventable.
There is an urgent need to develop strategic directions that address maternal health and aim at decreasing maternal mortality in the Eastern Mediterranean Region, using our knowledge of the situation and our understanding of useful interventions and setting them into one comprehensive framework.

Current situation of maternal health in the Region

Relationship to the Millennium Development Goals

In 2000, the United Nations General Assembly adopted the United Nations Millennium Declaration, which set eight Millen- nium Development Goals (MDGs) to be achieved by 2015. The fifth goal addresses the need to improve maternal health and sets a target of achieving a 75% reduction in the maternal mortality ratio by 2015 from the level in 1990. For this target, two indicators have been selected to help track progress: maternal mortality ratio and proportion of births attended by skilled health personnel.

Maternal mortality ratio (MMR)

The average MMR in 2004 was estimated at 370 per 100 000 live births, compared to 465 per 100 000 live births in 1990, a reduction of only around 20%. The regional target for this period, established in 1990 by the Thirty-seventh Session of the Regional Committee for the Eastern Mediterranean in resolution EM/RC37/R.6, was to reduce the Regional MMR by 50% between 1990 and 2000.
However, there are great variations and disparities in maternal mortality levels between countries of the Region. Some countries have achieved over 75% reductions compared to levels in 1990 with MMRs reaching as low as 0, while other have not exceeded 30% from levels in 1990, with the maternal mortality ratio reaching up to 1600 per 100 000 live births.

Proportion of births attended by skilled health personnel

Skilled birth attendants are defined by the World Health Organization as “trained midwives, nurses, nurse-midwives or doctors who have completed a set course of study and are registered or legally licensed to practice”. Most maternal and newborn deaths occur around the time of delivery or shortly thereafter. Some 80% of maternal deaths are due to a few direct obstetric complications (sepsis, haemorrhage, eclampsia, obstructed labour and abortion) and most could be prevented or managed if the woman had access to a skilled birth attendant with necessary back-up and support.
According to the Millennium Development Goals, 80% of all births should be assisted by skilled attendants by 2005, and 90% by 2015. However, in 2004, it was estimated that only 53.3% of births in the Eastern Mediterranean Region were attended by skilled attendants, compared to 36% in 1990, making only a 48% increase in this proportion.

Strategic directions for making pregnancy safer in the Region

Central strategic objective

The central objective of the World Health Organization’s Making Pregnancy Safer (MPS) strategy is to ensure safe pregnancy and childbirth through the availability, access and use of quality skilled care for all women and their newborns. As a priority, skilled care should be ensured at every birth. Skilled care in maternal and newborn health refers to the process by which a pregnant woman and her newborn are provided with the necessary care which must include, apart from care in normal (uncomplicated) births, timely referral and management of complications if they arise. The essential component of skilled care is the presence of a skilled attendant and other key skilled professionals supported by an appropriate environment with access to basic supplies, drugs and relevant emergency services. Skilled care should be provided within a continuum of care. This continuum extends from care and support in the home, to care by a skilled attendant throughout pregnancy, childbirth and the postnatal period, to the care needed in case of complications.

Guiding principles

The core values upon which the strategic directions are based include promoting maternal and neonatal health as a human right; promoting gender equality, while tackling the lower status of women and discrimination against women; tackling inequities in health, with priority attention to poor and underserved groups; and improving maternal health using a culturally sensitive approach that takes into consideration the sociocultural dimensions and specificities of the Eastern Mediterranean Region.
The strategic directions highlight the importance of certain operational principles, such as the existence of a continuum of care at all levels of the health system from the household to the first service level to the higher level service site. Primary care should be strongly connected to a referral system in order to effectively manage life-threatening complications. In addition, quality of care should be maintained in order to effectively manage routine cases as well as complications. Addressing providers’ needs and community views, particularly those of women, on the quality of service provision is the key to ensuring improved quality and increased access and utilization. Furthermore, the MPS strategy focuses on links with family planning services, other reproductive health services and other aspects of primary health care, including management of malaria and HIV where applicable. Furthermore, partnerships are an important principle in shaping the MPS strategic directions, as they have been shown to bring down mortality rates in a range of contexts. Such partnerships could be created between governments, civil society, professional groups, international agencies and donor groups. Finally, good governance, peace and security remain vital components of a sustained effort to improve the health and survival of mothers and their newborn babies, and are especially relevant to the Eastern Mediterranean Region.

Priority actions

Achieving political commitment

Achieving the objective of skilled care for all women and their newborns requires strong political will. Therefore, it is necessary to develop national maternal health policies which prioritize the interventions required to reach the population groups most in need, bring all elements of maternal health together in one policy document, reallocate resources and serve as a reference for partners to help guide their assistance to countries and achieve the MDGs.
Well-managed advocacy, based on solid data, to create awareness of the scale and consequences of the problems of maternal and perinatal mortality in a country must also spread beyond the experts working in the area of maternal and child health and include other stakeholders in government, policy-makers, religious leaders, academic institutions, professional associations and nongovernmental organizations, as well as community and women’s groups. International organizations, nongovernmental organizations, local groups and the local media will have a key role to play in supporting governments in their efforts to mobilize resources.

Promoting a favourable policy and legislative environment

It is important to develop a human resources policy that is comprehensive and that takes into consideration the country-specific context. Such a policy would serve to regulate issues such as licensing of health providers and skilled attendants and the extent to which each can perform certain procedures. Removal of unnecessary restrictions from policies and regulations in order to create a supportive framework for ensuring skilled care for all women and their newborn babies is likely to contribute significantly to improved access to services.
Ensuring that regulations and standards are in place is important to guarantee that the necessary medicines, equipment and supplies are available on a consistent and equitable basis and meet international quality standards.

Ensuring adequate financing

Sustainable financing mechanisms should be set up so that actions to strengthen the health system can yield results. Improving health financing would reduce the extent to which people have to make large out-of-pocket payments at the point of service, increase the accountability of institutions responsible for managing insurance and health care provision, improve the pooling of health fund contributions across rich and poor and raise money through administratively efficient means. Such sustainable financing mechanisms would play the greatest role in countries of the Region that suffer from poverty by offering financial protection to those who need it most.

Strengthening the delivery of health care services

Maternal health should be embedded into an integrated and comprehensive set of primary health care services that are intended to reach out to all parts of the population. To realize these primary health care objectives, health care for women and newborn babies should be underpinned by reproductive health programmes, such as family planning, and also strongly linked with other key primary health care components, such as the prevention and treatment of malaria, wherever necessary.
To strengthen health care delivery and create functioning systems the provision of an effective, skilled and appropriately trained workforce is fundamental. The health system requires a comprehensive human resources policy which is able to manage different workforce issues, such as shortages, drain of human resources, deployment and motivation, which strain health care service delivery in several places in the Region. The health system needs to be equipped with sufficient numbers of skilled workers to deliver essential services at each level of care. The continuum of care also requires a functioning referral system for the management of pregnancy-related complications in an emergency.

Empowering women, families and communities

A number of strategies are required to work effectively with women, their families and communities to strengthen their capacities to provide appropriate care in the home; to make healthy decisions and to act upon those decisions, including the decision to seek care at other levels of the continuum when needed; and to assume their important role as partners in improving maternal and newborn health. The strategies of education, community action, partnerships, institutional strengthening and local advocacy have been identified, as have key interventions to contribute to the empowerment of women, families and communities to improve and increase their control over maternal and newborn health, as well as to increase access and use of quality health services.

Strengthening monitoring and evaluation for better decision-making

Effective monitoring and evaluation is essential to programme and service improvements. Tracking progress is also a potent tool for advocacy and can galvanise political commitment for improving maternal and neonatal health and survival. Improved monitoring of maternal and neonatal deaths is a priority, especially in Member States where vital registration is incomplete. Approaches should be tailored to country contexts, but the application of facility audits, special surveys for women of reproductive age, verbal autopsies and even special questions administered through the census have all been and can be used successfully. However, the eventual aim should be the strengthening of vital registration and improvements in country health management information systems. This would help detect epidemiological patterns and maternal morbidity and mortality trends, in order to identify appropriate interventions that address real needs in the community.

Implementation framework

Implementing the priority actions just described will depend on country contexts. The following key issues for implementation are intended as a guide for prioritizing strategic elements in countries.

Building on existing country efforts and maintaining gains

It is vital to build on existing country efforts and strengthen the processes, structures and systems for planning, implemen- ting and evaluating the national safe motherhood programme. Hard-fought gains should be maintained and country processes respected. It is evident that it may not be possible to implement all activities in the strategy simultaneously, or in the same way throughout a country. The priority actions can be introduced and scaled up at different rates and in alternative ways based on local needs and available resources. The plan of action must allow for local decision-
making, prioritizing and adaptations to meet the particular needs of a district or region.

Partnerships—a participatory approach

Strong political commitment and strategic partnerships at all levels are crucial for gaining the necessary intersectoral collaboration. All stakeholders at both national and local levels, including public and private providers, all related programmes and representatives from women’s and community groups, should be actively involved from a very early stage in identifying priorities, assessing needs, developing, implementing, monitoring and evaluating maternal and newborn health programmes and plans. The involvement of other ministries, such as those dealing with education, finance, transportation, social welfare and women’s affairs, is critical. In addition, working closely with nongovernmental organizations and the private sector in a systematic and regulated manner would allow the tapping of resources, be it financial, human or logistic, and strengthen and regulate the participation of these two sectors that are increasingly playing a significant role in shaping the health of the populations of the Region.

Strong programme management and planning

A high-level national multidisciplinary taskforce or committee, with the responsibility to take action and influence policy change, as well as to coordinate and oversee all partners’ efforts, is required. Actions taken by such a taskforce should be underpinned by the strongest available evidence. Efforts should be focused on identifying the components which need strengthening in the health system for building the continuum of care. Evidence-based interventions should be promoted and national standards for the essential package should be established or revised, with clear lines of accountability and reporting and monitoring of progress.

Conclusion

Too many women in the Region are suffering and dying due to pregnancy-related causes. Most of these deaths are potentially preventable. We now know what can be done to prevent these deaths. Tens of thousands of mothers in the Eastern Mediterranean Region could be saved using the knowledge and experience we have today. The challenge is to transform knowledge and experience into action. This requires the commitment of Member States, who have a unique opportunity to accelerate reduction of maternal mortality at this time, with support from the World Health Organization and other concerned partners. What remains is for all those involved to amalgamate efforts and join forces in coordinated action to decrease maternal mortality and bring closer the achievement of the Millennium Development Goals.