Deliberate Indifference: Why aren’t we making progress in reducing maternal deaths?

This afternoon I was reading Allan Rosenfield and Deborah Maine’s seminal article, “Maternal Mortality—A Neglected Tragedy: Where is the M in MCH?” It was written almost 25 years ago, but could just as well have been written yesterday, since so little progress has been made in addressing maternal deaths in the years since.

Indeed, the statistics have barely moved. A report released last week by the Alan Guttmacher Institute (AGI) and the United Nations Population Fund (UNFPA), noted that while the maternal mortality ratio has decreased by about 6% since 1990, the absolute numbers of maternal deaths have remained about the same. In 2005, 533,000 of the estimated 536,000 maternal deaths occurred in developing countries, more than half of them in sub-Saharan Africa. The causes of maternal deaths also remain the same: hemorrhage, hypertensive disorders, infection, obstructed labor, and unsafe abortion.

Reducing maternal deaths is not difficult in theory.  The best way to do it is to ensure that every woman gives birth with the assistance of a skilled health professional, or at least can get emergency obstetric care when complications arise.  Reducing unintended pregnancies by ensuring that women have access to family planning and are empowered to make decisions about the number and spacing of their children could also make a huge difference, as most deaths occur in women who give birth in the extremes of their reproductive lives or among women who have already had four or more children.  Decriminalizing abortion and ensuring that all women who need abortion have access to safe, legal procedures could reduce maternal deaths by about 68,000 a year alone.  Giving women the education, services and tools they need to protect themselves from HIV infection, malaria, and anemia could also make a huge dent.

Yet the reality is something altogether different.

 Women at a community meeting on health in their village in Tigray Region, Ethiopia.

Women at a community meeting on health in their village in Tigray Region, Ethiopia. Photo by S. Kowalski.

A month ago I visited a rural village about an hour’s drive from Mekelle, Ethiopia’s sixth largest city, where the government is implementing a 17-point health extension program. The program places health extension workers, with about a year of training, in rural areas to provide health education and basic services to communities. These services include family planning, encouraging pregnant women to get antenatal care and give birth in health facilities, HIV prevention, testing and treatment, the distribution of bednets to prevent malaria, and education about nutrition and sanitation, among other things.  The community members I spoke with told me how these small interventions made a big difference in improving health in their village, and they recognized the importance of women giving birth with skilled attendance.  But, the closest health outpost was a six-hour walk away and nobody in their village owned a motorbike or car to cut down the travel time.  They said they tried to help pregnant women make the walk before they went into labor, but weren’t always able to do so.  And if complications arose, there wasn’t much they could do. Some community members had mobile phones, but there were no ambulances that served their village.

The government of Ethiopia is building health outposts in rural areas, but they are still far away from overcoming many of the barriers that prevent women from getting the care they need.

Rosenfield and Maine observed that the systems necessary to reduce maternal deaths were not being established “partly because of lack of financial and human resources but largely because of lack of political will to face this problem.” This continues to be the biggest barrier to progress today.  According to AGI and UNFPA, if donors and developing country governments were to double the amount of money invested in family planning and maternal and child health in developing countries annually from $11.8 to $24.6 billion, and put in place the education and services necessary, maternal deaths could be reduced by as much as 70%.  This amounts to just $4.50 per capita.

When we know what needs to be done and we know how to do it, as Rosenfield and Maine said, “it is difficult to understand why maternal mortality receives so little serious attention from health professionals, policy makers, and politicians.”

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