COMMENTARY

Keeping Maternal Mortality Rate Down Around the World

Omar A. Khan, MD, MHS; A. Mushtaque R. Chowdhury, PhD, MSc

Disclosures

June 09, 2010

Maternal Mortality for 181 Countries, 1980-2008: A Systematic Analysis of Progress Towards Millennium Development Goal 5

Hogan MC, Foreman KJ, Naghavi M, et al
Lancet. 2010;375:1609-1623

Study Summary

Reduction in maternal mortality is one of the Millennium Development Goals, endorsed by a wide swath of governments, aid agencies, and nongovernment organizations. It is a codification of the ethical imperative for which pioneers in the field, such as the late Dean Allan Rosenfield, MD of Columbia University Mailman School of Public Health, worked their entire professional lives.[1]

For many reasons, the measurement of maternal mortality has been a challenging endeavor. The Lancet article by Hogan and colleagues is an important attempt to reexamine the issue and suggest a new way of addressing it with data from vital registration, censuses, surveys, and verbal autopsies. On the basis of this new approach, the investigators recalculated the maternal mortality ratios (MMRs) for 181 countries, a daunting but useful effort.

These new estimates did bring some surprises. The new analysis indicates that 6 countries (India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of Congo) account for most maternal deaths in the world -- a not surprising but sobering statistic. Of note, these are not the only health issues faced by these countries; too frequently, underlying problems that seem to have nothing to do with health actually have everything to do with it. Whether the problem is war, civil unrest, social injustice, natural calamities, or crushing poverty, these determinants of health ensure that, unfortunately, the names of these countries will crop up on other lists as well. One example: The World Health Organization (WHO) confirms that the only 4 remaining polio-endemic countries in the world (India, Nigeria, Pakistan, and Afghanistan) are from this same group.

It is encouraging that progress has been made across all regions. Even in the South Asian region, where the study found 3 of the highest-burden countries -- Afghanistan, India, and Pakistan -- successes have been realized. First, all 3 countries registered a drop in the MMR between 1980 and 2008 (the other data points were 1990 and 2000). With the exception of Afghanistan, the rate of decline was steady throughout the intervals. Afghanistan, with its myriad challenges to even the most basic of health determinants, registered an increase from 1640/100,000 live births in 1980 to 1957/100,000 live births in 2000; the MMR then declined to 1575/100,000 live births in 2008.

Second, other countries in the region -- notably Bangladesh and Bhutan -- registered significant drops in the MMR during the same time. For Bangladesh in particular, the drop was very sharp, from 1329/100,000 live births in 1980 to 338/100,000 live births in 2008. The Bangladesh MMRs as estimated by the investigators also raise some other issues. For one, the figure for 1980 may well be an overestimate; the first national study on maternal mortality was done only in 2001, and before this, most estimates were based on small-scale surveys (none of which indicated as high a ratio as 1329). In any case, the big (53%) drop between 1990 and 2008 (from 724 to 338) is very interesting and encouraging.

Viewpoint

The investigators suggested 4 reasons for the overall drop in the global MMR (which, from the Bangladesh experience, resonate well): (1) decrease in total fertility rates; (2) higher household and personal income; (3) more maternal education, and (4) an increase in attendance at birth by skilled personnel.[2] In addition, the enhanced role and status of women at household and broader society levels, brought about by the work of civil society organizations, may also have had a positive effect.[3]

The other interesting statistic is for Rwanda, which registered a nearly two-third reduction between 2000 and 2008. Thailand, on the other hand, registered an MMR that remained stagnant between 1990 and 2008. Thailand's rate was already low in 1990 (44/100,000 live births) and a stagnation warrants a new look at the current strategies for reducing the maternal mortality further.

The United States, meanwhile, has remained essentially steady to somewhat worse: from 12/100,000 live births in 1980 to 17/100,000 live births in 2008 (the 1990 and 2000 figures were 12 and 13, respectively). It is doubly disappointing that in a 2-year period during which global health lost 2 of its most valuable leaders -- Dr. Rosenfield and Carl E. Taylor, MD, DrPH (the innovator of community-based primary healthcare), both Americans -- the United States has not mirrored the striking progress made elsewhere. In fact, the United States is among the very few countries that registered an increase in maternal mortality.

One reason suggested for the increase is a revision in how maternal deaths are recorded. For example, "late" maternal deaths are now recorded, and US death certificates now include pregnancy as a separate item. These changes probably contributed to some of the data increases that were seen. We do not believe this reflects the entire reason for the increase, however. In fact, one of the possible reasons should be clear to anyone practicing adult medicine in the United States: the increase in chronic diseases that complicate pregnancy (an entire recent issue of an obstetric journal reviewed the various medical issues as they relate to the pregnant patient[4]). Obvious examples include the related conditions of obesity, hypertension, and diabetes. The epidemic levels of these conditions are well documented for the United States. It is small wonder, then, that the same women who have these conditions before becoming pregnant would then go on to have peripartum and postpartum deaths as a consequence of hemorrhage, preeclampsia, infection, and venous thromboembolism, among others.

In essence, what we are probably seeing in the United States is worsening prepregnancy health status in childbearing women that manifests in poor outcomes, such as maternal morbidity and mortality. This may not be generalizable across all groups, but it is clear from the clinician's standpoint that among high-risk groups, including non-Asian minorities and women of low economic and educational status, their overall health is poor even before the added stress of pregnancy. It is concerning that we have the potential to couple this with a general loosening of the safety net.

In recent times, a lot of discourse has transpired about universal health coverage as an important strategy to ensure good health for all.[5] Of interest, universal health coverage is used primarily to cover curative care. In an ideal situation, it would also cover comprehensive "primary prevention" of pregnancy-related complications, which would include preconception risk reduction for a variety of conditions and ready access to reproductive health services, including counseling, contraception, and pregnancy termination.

Whereas healthcare reform is much talked about, in truth, it faces a great deal of opposition from all sides; certainly, discussions of comprehensive, universal primary healthcare and prevention stimulate loud dissent (ironically, sometimes from the very groups that may stand to benefit the most). Resistance to government-coordinated healthcare (existing Medicare and Medicaid programs notwithstanding) is further complicated by the fact that commercial or profit-motivated schemes would rarely find it viable to cover care for the poorest and neediest of our society.

It is beyond the scope of this brief commentary to discuss all of the social determinants of health that influence the end goals of healthy mother, child, and family. However, it is clear from the work of the WHO Commission on Social Determinants of Health and its chair, Sir Michael Marmot, that addressing these determinants in a comprehensive manner, through public and public-private nongovernment partnerships, must not just be another plank in the platform but also form the foundation itself. Perhaps the disappointing figures from the United States will finally spur some action in the right direction.

Acknowledgement

The authors are grateful to Ariel Pablos-Mendez of the Rockefeller Foundation and Suwit Wibulpolprasert of the Thailand Ministry of Public Health for their insights on an earlier version of this commentary.

Abstract

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