The Maternal Health Task Force: An Expert Interview With Ann K. Blanc, PhD

Katharine M. Hikel, MD

Disclosures

January 06, 2010

Editor's Note:

EngenderHealth is an international reproductive health organization, whose objective is to assist the world's poorest communities to improve health through contraception, maternity care, gender equity, prevention and care for HIV, and increased access to quality clinical services. In February 2009, the organization named Ann K. Blanc, PhD, as Director of its Maternal Health Task Force. The Maternal Health Task Force contributes to shaping collective efforts to improve maternal health worldwide, by "convening stakeholders and creating an inclusive setting to engage in dialogue, build consensus, and share information."

Dr. Blanc, a demographer by training, is a researcher and planner with extensive experience in international health. She has an interest in sexual and reproductive health, which includes maternal health.

Dr. Blanc spoke with Medscape about the current challenges that the Maternal Health Task Force faces, and about their vision for improving the worldwide health of childbearing women.

Medscape: How did you, as a demographer -- working with populations as statistics and groups -- become interested in sexual and reproductive health, which (clinically speaking) is a more personal and intimate field?

Dr. Blanc: Early in my career, in the mid-1980s, there was a lot of interest and concern about rapid population growth, especially in the developing world. It was widely believed by economists, development specialists, and others that population growth was an impediment to economic development, and as you may know, one of the main determinants of population growth is the fertility rate. The primary way that the fertility rate has declined is through the use of contraception.

Of course women's sexual and reproductive health is central to the discussion about contraception. It was clear through survey research that I was involved in at the time that there was a very large and unfulfilled demand for contraception and reproductive health services by couples in many developing countries, and that's what led me into this field.

Medscape: Along with contraception, what are the most pressing issues in maternal health right now, from a global public health perspective?

Dr. Blanc: In the year 2000, virtually all the countries in the world agreed to 8 goals called "United Nations Millennium Development Goals." These goals were a blueprint for ending poverty by 2015. They're very ambitious. One of the Millennium Development Goals -- Goal 5 -- is to improve maternal health. The fact that it was included among those 8 goals shows what an important problem it is, and how closely it is linked to poverty and other development issues.

It's been almost 10 years since we set those goals, and more than 500,000 women still die in pregnancy and childbirth every year, and little progress in bringing down that number has occurred over the last decade. Most maternal deaths occur in developing countries, and almost all are preventable. We know that because maternal death is a very rare event in the United States and in other developed countries. Although it's possible to prevent most maternal deaths, in most developing countries (with some notable exceptions), this is not yet happening.

This is why the Maternal Health Task Force, which is the initiative that I work on, concentrates its efforts on developing countries. What we really need now is the political will, and the funding that goes with that, to make maternal health a priority. It's a problem on which we could really make very significant progress if we put our minds to it and our money behind it.

Medscape: How do you get all of your programs' participants to agree on definitions? For example, "prenatal care" to some means "ultrasound every 6 weeks," but to others, it means "food, shelter, clothing" and perhaps "literacy and employment"?

Dr. Blanc: Our mandate at the Maternal Health Task Force is to build consensus, catalyze innovation, and help improve communication within the maternal health field through knowledge sharing; it's true that people don't always agree on everything. What we do is provide a platform for people working in the field at the international level to have those discussions and debates. This platform is something that was missing from the maternal health field until quite recently.

There's a variety of things that we do. We convene expert groups; we convene technical meetings; next year, in 2010, we will have a Global Health Conference, which will be a technical and programmatic conference, that we expect will include about 500 people working in the maternal health field, at which many of these sorts of issues will be discussed. We also have a Website that allows for online and virtual discussions to take place.

Medscape: One of the goals of the Maternal Health Task Force is to work with "partners and stakeholders" -- political leaders, entrepreneurs, and health professionals.[1,2] Are the identified underserved communities considered "stakeholders" in this initiative, and do they have a say in the development of plans for their healthcare?

Dr. Blanc: Our stakeholders -- participants in the Maternal Health Task Force -- are people who are working in the maternal health field: health professionals; program managers; policy makers; researchers; and advocates -- anyone working to improve maternal health. Anyone can join our efforts by going to our Website at http://www.maternalhealthtaskforce.org and becoming a member. Within our mandate, however, we have a particular focus on bringing in the voices of those working in maternal health who aren't usually heard, especially at the global or international level, including local organizations working on the ground in developing countries. Those are the people who are closest to what is going on in those countries. Those are the ones who are working in the field. They are definitely our stakeholders. Ultimately, of course, our stakeholders are women and their families in developing countries.

Medscape: You mentioned contraception as a major component of women's health; in the Western world, we take birth control for granted. Is the Maternal Health Task Force looking at ways of expanding access to contraception? How do you address the question of abortion, especially in countries where women are seriously harmed or dying from illegal procedures?

Dr. Blanc: It's interesting because there's been a lot of disagreement in the maternal health field about the most important interventions. What are the things that need to be emphasized? In the last several years, the field has come to some consensus on the best interventions for reducing maternal death and morbidity. Some people call these the "Core Four." The first one is comprehensive reproductive health services, which includes contraception, so it's absolutely central to what we are doing. In fact, we commissioned some research that shows that there would have been about 1.5 million more maternal deaths over the last 15 years if fertility had not declined as a result of contraception.

There are tens of millions of women, according to research, in the developing world who would like to either limit or delay their next birth, and who do not have access to contraceptive services. It's very important.

The consequences of unsafe abortion are one of the most significant causes of maternal death in most countries, and of course improving access to contraception has a major role to play in reducing maternal mortality and morbidity from this cause.

Medscape: The implementation of the Lady Health Workers program is one way that Pakistan has compensated for the scarcity of health providers in provinces that may have only 1 or 2 pediatricians in residence.[3] In this program, women are trained to provide basic healthcare for their own communities of up to 10,000 people. By the end of 2006, 96,000 Lady Health Workers were in the system, with evidence showing improved health outcomes in participating populations.[4] Is the Maternal Health Task Force involved with similar grassroots healthcare efforts? How is the Maternal Health Task Force addressing the particular challenges that accompany resource-limited settings?

Dr. Blanc: This is another central issue in maternal health: the shortage of skilled health workers. It's a problem that many countries are facing, and they are addressing it in a variety of ways. The Lady Health Workers program in Pakistan recruits and trains community members to provide basic health services in the community setting. These are people who are not usually working in healthcare facilities, but are providing basic health services, including contraceptive services, in the community, in people's homes. The evidence suggests that these programs can be effective, but they have to be well implemented; there has to be good training and good supervision of the health workers.

Other countries are doing similar things. Ethiopia, for example, has a very large community health worker program; they have trained 45,000 health workers to provide a range of maternal and child health services.

At the Maternal Health Task Force, we provide a space for the maternal health community to share their experiences with these kinds of programs. We provide people with an opportunity to report these experiences, to share what they're doing, to evaluate programs, and to provide a platform for others to pick up these types of programs.

Medscape: As nations adopt Western delivery systems, hospitalization rates for childbirth and interventions increase, sometimes dramatically. As an example of this, in Hangzhou, China, governmental insistence on Western-style hospital birth has led to a 100% rate of cesarean delivery.[5] The American Congress of Obstetricians and Gynecologists (ACOG) says that all births should occur in hospitals.[6,7] In a recent Maternal Health Task Force presentation, for example, "poorly developed health systems" is defined as "mostly home births," and "well-developed health systems" as mostly "facility births." Granted, home births in developing countries are associated with high mortality rates, but overmedicalization of births in developed nations also poses dangers. How would the Maternal Health Task Force partners perceive this issue, and how would they balance the challenges in both delivery systems?

Dr. Blanc: This is another area of debate in the maternal health community. All births can't take place in facilities right now; that is an unrealistic recommendation in many settings. The facilities do not exist, and even if they did exist physically, there aren't enough professionals to staff them. Also, as you pointed out, insisting on facility births sometimes leads to unintended and very strange consequences. What the international and global maternal health field has agreed on is that the important elements of delivery care are that birth takes place with the assistance of a skilled birth attendant -- not necessarily within a facility, but with a skilled birth attendant; that women should have access to emergency obstetric care when it's needed; and that women and newborns should have postpartum care -- and that doesn't necessarily need to happen in a facility, but it needs to happen with a skilled person. At some point in the future, perhaps the recommendations for the developing world will change, but right now the consensus is that those 3 elements are needed.

Medscape: A statement from the Harvard Initiative on Global Health reads:

Current perspectives on women's health are still too often narrowly framed as related to reproductive or sexual roles (such as prenatal care, maternal mortality, breastfeeding and other childrearing behaviors, sexually transmitted diseases, and HIV/AIDS), at the expense of understanding constraints of poverty, social status, legal barriers, cultural norms, and economic and educational opportunity.[8]

Poverty and education are often the root causes of inadequate or poor health services and outcomes. How does the Maternal Health Task Force fit its mission into a view of these larger problems?

Dr. Blanc: That statement from the Harvard Initiative is right: Women's health, and more specifically maternal health, are often viewed narrowly as clinical medical problems that require only clinical medical solutions; however, the reality is that maternal health is the consequence of many other factors. Women's roles and values in society are very important, as are poverty, education, economic status, and so on. Because of this complexity, one of our objectives is to engage what we call allied sectors in the maternal health field. For example, we're engaging with people who work in transportation, and in the communications sector, to talk about issues related to emergency transportation for women with obstetric emergencies.

In most developing countries, ambulance services don't exist; you can't pick up the phone and call 911; and if a woman is giving birth at home, and has an obstetric emergency, it's up to her family and her community to get her to a health facility, and sometimes those health facilities are very far away. This is not an issue that has a solution that's going to be created by the health sector alone: It's a transportation problem; it's a communications problem. This is why it's important to engage other sectors with the field of maternal health.

Medscape: The Maternal Health Task Force is sponsored by EngenderHealth, which belongs to the Partnership for Maternal, Newborn & Child Health (MNCH), a part of the World Health Organization (WHO). It can be difficult to differentiate the work that is happening in the field vs at the organizational level and whether the people most in need are benefiting directly from these efforts. For example, in India, the area mentioned in a recent Maternal Health Task Force presentation, it's possible that women don't need fewer home births; they may need better homes and better-trained attendants to go to those homes. Is there any accountability or review on this? Can you tell us what's happening on the ground?

Dr. Blanc: There are many organizations -- EngenderHealth and many others, both international and local -- that are working on maternal health, and it can be very hard to understand all the pieces and how they fit together, even for those of us who spend our lives in this world! For that reason it's important that organizations talk to each other; that they share best practices; that they work on developing evidence-based policies; and providing a structure and a place to do that is what we are trying to do. There are many others working on maternal health at many different levels. India is a good example of a country where there are many actors working on maternal health at many different levels. For example, state governments in India are very important in providing healthcare in general, and maternal healthcare in particular; they are actively experimenting with many ways to improve health. One example is the state of Gujarat, where the state government has contracted with private obstetricians/gynecologists (Ob/Gyns) to provide delivery care for poor women; this has increased substantially the proportion of poor women who are delivering with skilled attendants in that state. This is a model that is not so unusual in the United States, but it's quite unusual in India; it's a public-private partnership that appears to have been quite successful.

Another thing that they're trying in India is providing women with financial incentives -- actually paying women to come into facilities to deliver. Because they have such a shortage of Ob/Gyn physicians, they've also trained non-Ob/Gyn physicians to do cesareans in some places. Therefore, many things are happening on the ground -- very exciting and innovative things by a whole range of different actors.

Medscape: EngenderHealth is attempting to work on the root causes of social and health problems, and gender inequity is one example. Outreach programs targeted to men are available in what might be perceived as some of the most male-dominant societies in Africa. How could Western-style public relations help to transform or change centuries of cultural tribal mores and beliefs?

Dr. Blanc: I don't think they can! In international work on sexual and reproductive health, men used to be ignored, more or less. But more recently, men are recognized as being absolutely critical to women's health. Women know that. Therefore, organizations that work in this field, including EngenderHealth, are working on gender inequality and other issues in various ways. Some of that is public education (what you might call public relations), using various kinds of media campaigns, street theater, and other events that look at the role of men in women's health. However, there are other kinds of activities that organizations are working on as well, for example, working with healthcare facilities to provide men with quality care for their own health, to make the facilities where they go with their wives more male-friendly, and more inclusive of men in women's decisions. These are practices that facilities are not really used to; they're used to just dealing with women, and not welcoming men. So in some cases, the whole culture of the health facilities has to change.

Medscape: According to the WHO/Partnership for MNCH "Strategy and Workplan," "The continuum of care concept is not well understood and does not figure prominently in planning MNCH activities. Partners are just now becoming aware of its value-added potential.[9]" How does the Maternal Health Task Force view this issue, and what are its potential solutions?

Dr. Blanc: "Continuum of care" is a phrase that expresses the recognition that maternal, newborn, and child health are all intricately linked with each other; that linking health services for mothers, newborns, and children can be very effective, very efficient, and very cost-effective as well. In the past, these different services have often been provided in a "vertical" way; they haven't been integrated; they've been separated into their own separate silos. However, if you think about it, it makes a lot of sense to do a check on a new mother when you're also checking her newborn baby -- and that often doesn't happen. So the continuum of care is a way of making those linkages very explicit.

At the same time, it's important to keep all of the elements of maternal, newborn, and child health strong. One way to think about the continuum of care, or MNCH, is a 3-legged stool; its legs are maternal health, newborn health, and child health. We want the stool to be strong, and the only way it's going to be strong is if all 3 legs are sturdy. At the Maternal Health Task Force, we see ourselves as part of the maternal health leg of that stool. We're trying to build a coherent, knowledgeable community that is moving together with the newborn and child health communities, all towards the goal of reducing maternal morbidity and mortality, but also improving newborn and child health.

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