Roundtable: Is Pregnancy Getting Safer for Women? Dear Minister

Mothers are still dying during childbirth in your country. We write to you for this reason and because this is a crucial year for accelerating progress towards the Millennium Development Goal for maternal mortality – a three-quarters reduction by 2015.¹ Over 99% of the world’s maternal deaths occur in developing countries.² The women dying are in their prime of life: they are crucial to society and the economy; they sustain the next generation; they make-up more than half the workforce. But this is not just your country’s problem. Continuing high levels of mortality in mothers and babies is a global collective failure, shared with other developing nations and with the donor and international community.³ 2007 is the 20th anniversary of the Safe Motherhood Initiative to reduce maternal mortality. It is a year of opportunity for your country and for you to take action.

We urge you to make skilled delivery care a high priority in your country’s development plans. The vast majority of mother and baby deaths occur at the time of childbirth,⁴ but less than half of all deliveries in the developing world take place with a health professional and in some countries the proportion is below 10%.⁵ An even smaller fraction of women have ready access to hospitals for emergency obstetric care when serious complications arise. For many developing countries, these proportions have not changed significantly over the last 20 years,⁶ and indeed have worsened in some regions and for the poorest households. Many women, well-over three-quarters in most nations, do however attend at least once for antenatal care, which shows a willingness to use services when they are provided. There is strong evidence from research and from countries which have dramatically reduced their maternal mortality, such as Egypt, Honduras, Malaysia, Sri Lanka and Thailand,⁷ to show that giving all women the opportunity to deliver with a skilled health worker and with access to emergency obstetric care is one of the best ways to improve the survival of mothers and babies. This is why donors and international agencies are now proposing to move towards results-based financing of maternal, newborn and child health services.⁸ As you know, this approach has been used by the GAVI Alliance^* to help achieve immunisation targets.⁹ Countries may soon be able to secure additional funds from donors in return for targets they set themselves for increasing the proportion of deliveries with skilled attendants. This is a tremendous opportunity to mobilise the financial resources needed to save the lives of mothers and babies.

Precious resources should be used where they will have the most effect. Providing delivery care is not as simple as immunisation, but it does mean that countries could also strengthen their overall health system.⁵ The goal must be universal access to skilled delivery care, meaning that all women should be able to deliver with a competent midwife who can refer promptly to a functioning hospital if the need arises. A phased approach will be needed to achieve this goal, both over time and between different regions, given the diversity of contexts within your country. In the immediate term, you may need to continue to depend in some areas upon health workers who are not professionals, whilst training more midwives and doctors and making sure the health centres and hospitals where they work are fully functional.

Some countries, like Indonesia, have boldly tried to take delivery care closer to communities, but a major evaluation has shown that low uptake, poor access to emergency care, and high levels of maternal mortality persist.¹⁰ Recently the Lancet has argued, drawing upon the best available evidence, for health centres (primary level facilities providing basic essential obstetric care) as the optimal place for most deliveries.¹¹ Many countries already have health centres, and could consider redeploying some of the midwives from antenatal clinics or the community to ensure a 24-hour delivery service. This could be a cost-effective strategy since several women can be attended in the health centre at the same time by teams of midwives, backed up by timely access to doctors and emergency care at the district hospital. It will of course be essential to monitor such a strategy to demonstrate progress to your people and to external partners.

The potential gains from scaling-up of skilled care at delivery are enormous: we estimate that the number of maternal deaths could be halved by 2015, at an extra cost to your health budget of between US$0.22 and $1.18 per capita.⁵ But there are two potential obstacles to achieving this impact. Firstly, you must ensure that the quality of delivery care is acceptable. Poor quality care costs rather than saves lives, and women will not want to attend. You will need to continue to work with the professional bodies in your country to support them in assuring standards of care. Secondly, you will need to ensure that the poorest women are reached. We know that the poor–rich gap in skilled delivery care is over three-fold in many countries. Studies have now also provided firm evidence of an even bigger gap in emergency caesarean sections¹² and in maternal mortality.⁹ It is clear that progress cannot be made if the poorest women are ignored – this is where the burden of mortality is greatest. Your country has made commitments to reducing the poor-rich gap in health as part of Millennium Development Goal 1, and should ensure any skilled attendance strategy also helps to narrow rather than widen the divide.

The financial barriers to delivery care in many countries are enormous. In Burkina Faso, for example, on average, a normal delivery costs US$39, rising to US$124 for a caesarean section, and with transport costs to reach health facilities in addition.¹³ Reducing financial barriers to skilled delivery care for women from the poorest regions should be a priority, perhaps by exempting emergencies initially. These are not the only barriers women face, but their removal is a necessary condition for progress in preventing maternal deaths. Moreover, experience on overcoming financial barriers is accumulating. Ghana for example, exempted all delivery care fees, and an evaluation showed a marked increase in uptake.¹⁴ However, because the poorest women still faced travel costs, it was the wealthiest that benefited the most. In Nepal, on the other hand, the Government has introduced a voucher scheme to pay women to come for delivery care, with those coming furthest tending to be the poorest and paid more.¹⁵ Emergency maternity services must be boosted to cope with the extra demand. In Sri Lanka, poor women were encouraged to use the same delivery services as the less poor, and together with strengthened emergency care at public hospitals, this led to a dramatic decline in maternal mortality in less than a decade.⁶

There are just seven years left before your commitment to the Millennium Declaration will be judged by the public, by neighbouring countries and by international partners. You need to act now on the commitment to women and babies. This commitment requires sustained action over many years, and must rise above the politics of “quick wins”. Reducing financial barriers to accessing skilled delivery care, and particularly to emergency care, will help save lives and money both in the short and longer term. In many countries there is currently a lively debate about abolishing user fees. Indeed, some African nations have recently taken the bold step of removing charges for maternal and child health services. A special case can and must be argued for delivery care: it is the only service in which the lives of more than one individual are directly at stake. The catastrophic costs of death and of life-saving obstetric interventions are borne not just by families and communities but also society and the economy as a whole. There can be no greater contribution from a country’s leaders than to assure the lives of the next generation and of those who bear the joys and the risks of childbirth. Reducing financial barriers to skilled care at delivery would be a lasting legacy. We urge you to act now.

Acknowledgements

This paper draws upon work undertaken as part of an international research programme – Immpact (<www.immpact-international.org>), funded by the Bill & Melinda Gates Foundation, Department for International Development, European Commission and USAID. The funders have no responsibility for the information provided or views expressed in this paper. The views expressed herein are solely those of the authors. We would like to acknowledge helpful comments on an earlier draft of this paper from our colleagues: Dr Julia Hussein, Dr Carine Ronsmans, Alec Cumming and Sue Fairburn.

Notes

* Formerly the Global Alliance for Vaccines and Immunization.