In this short video, Dr Mathai talks about maternal mortality. Although the number of global maternal deaths have fallen dramatically in the last 20 years, maternal mortality remains unacceptably high. Many of deaths can be attributed to conditions such as high blood pressure, bleeding during pregnancy, bleeding after child birth, prolonged labour or infection. However, Dr Mathai states that many deaths can be attributed to other reasons, such as a delay recognising that there is a problem or deciding to not seek care. There may also be a delay reaching appropriate care in time. The World Health Organization (WHO) and its partners believe that maternal death surveillance and response (MDSR) is key approach to addressing some of these challenges. MDSR will provide vital evidence on each death and what could have been done to avoid or prevent the death. Recommendations can then be made to prevent other women dying in the same way.
Dr Matthews Mathai is an obstetrician with experience in developed and developing countries. He previously worked as a Professor of Obstetrics and Gynaecology at the Christian Medical College Hospital, Vellore, India. He was also Co-Director of the Regional Training and Research Centre in Reproductive Health at the Fiji School of Medicine, and was thus involved in training of health workers in the Pacific island countries. In addition to clinical work, teaching and research in maternal and perinatal health, Dr Mathai has been a major contributor to the WHO manual entitled Managing Complications in Pregnancy and Childbirth.
Background to maternal mortality
According to the WHO Factsheet on maternal mortality, approximately 800 women die from preventable causes related to pregnancy and childbirth each day. The vast majority of these deaths (99%) occur in developing countries. Although maternal mortality dropped by almost 50% between 1990 and 2010, maternal mortality worldwide remains unacceptably high. The burden is more pronounced in poor, rural areas – with young adolescents facing higher risk of complications and death as a result of pregnancy than older women.
Millennium Development Goal 5 focuses on improving maternal health, with Target 5.A. aiming to reduce the maternal mortality ratio by three quarters between 1990 and 2015, and Target 5.B. aiming for universal access to reproductive health by 2015. In response, the key working areas identified by the WHO are as follows:
- Strengthening health systems and promoting interventions focusing on policies and strategies that work, are pro-poor and cost-effective.
- Monitoring and evaluating the burden of maternal and newborn ill-health and its impact on societies and their socio-economic development.
- Building effective partnerships in order to make best use of scarce resources and minimise duplication in efforts to improve maternal and newborn health.
- Advocating for investment in maternal and newborn health by highlighting the social and economic benefits and by emphasising maternal mortality as both a human rights and equity issue.
- Coordinating research, with wide-scale application, that focuses on improving maternal health in pregnancy and after childbirth.
Although evidence suggests that in Eastern Asia, Northern Africa and Southern Asia, maternal mortality has declined significantly, the maternal mortality ratio in developing regions is still 15 times higher than in the developed regions. Further information on the progress towards achieving Millennium Development Goal 5 – improving maternal mortality – is available through a UN Factsheet.
Maternal death surveillance and response
In 2013, WHO published a document offering technical guidance on MDSR. The document targets health care professionals, health care planners and managers working towards improving maternal health. It complements the WHO ‘Beyond the Numbers’ publication from 2004. It defines MDSR as a form of continuous surveillance that links the health information system and quality improvement processes from local to national levels, which includes the routine identification, notification, quantification and determination of causes and avoidability of all maternal deaths, as well as the use of this information to respond with actions that will prevent future deaths. It sets out the primary goal of MDSR as the elimination of preventable maternal mortality by obtaining and strategically using information to guide public health actions and monitoring their impact. This fits within the overall objectives of MDSR, which are to provide information that effectively guides immediate, as well as longer term, actions to reduce maternal mortality; and to count every maternal death, permitting an assessment of the true magnitude of maternal mortality and the impact of actions to reduce it. The key messages of this guide are as follows:
- MDSR is a system aimed at preventing maternal deaths and improving the quality of care through the dissemination and use of information for appropriate decision-making.
- Understanding the underlying factors leading to the deaths is critical for preventing future mortality.
- Data collection must be linked to action. A commitment to respond, that is to act on findings, is a key prerequisite for success.
- As a starting point, all maternal deaths in health facilities should be identified, notified, reported, reviewed, and responded to with measures to prevent future deaths.
- Improving the measurement of maternal mortality by working to identify all maternal deaths in a given area is imperative; without measuring maternal mortality ratios, we will not know if our actions are truly effective in reducing maternal deaths.
In an editorial for the Bulletin of the World Health Organization, Danel and colleagues (2011) focus on MDSR systems. They explain that introducing a system including maternal death identification, reporting, review and response, can provide the essential information to stimulate and guide actions to prevent future maternal deaths and improve the measurement of maternal mortality. They go on to argue that new technology, including the use of mobile devices to track and support maternal care, are presenting new opportunities. Innovative use of information and communication technologies have great potential to help countries improve birth and death registration systems.
For a MDSR system to work, it would require all health facilities to report all deaths of women during pregnancy, delivery and the postpartum period. A routine review of the deaths is an integral aspect of health-care quality improvement. At the community level, deaths would need to be reported by health, administrative or traditional authorities. Mobile phones would be a key tool for instant reporting. Data would need to be reviewed, compiled and analysed. The response to the evidence is the key to reducing maternal mortality rates. Much of the responsibility for follow-up actions lies with district and local health authorities. Active civil society engagement will be needed to ensure that the circumstances surrounding each death are fully elucidated and that there are comprehensive and feasible recommendations for follow-up action. Danel and colleagues (2011) conclude that MDSR systems have the potential to deliver real-time, frequent monitoring of maternal mortality levels, trends and causes, provided investments are made to assess the completeness of reporting and data accuracy as part of the system. If successful, such systems would be a major step forward in the measurement of maternal mortality.
A discussion note on MDSR explains that buy-in from the Ministry of Health will be essential if the system is to work. Active involvement of and support from health providers is critical, particularly for understanding and identifying solutions for the problems that contribute to maternal deaths in health facilities. There is also a need to engage the government for providing legal protection for families, communities and service providers and professional organisations for their role in ensuring medical practice is aligned to accepted standards. MDSR systems should make use of technological innovations where possible. Where this is not possible a pen and paper can work. MDSR systems can strengthen transparency and accountability. Also they can produce outputs that can be used for advocacy. The evidence generated from the MDSR process can support efforts to increase awareness of women and their needs is one way to use evidence to support the case for more or different resources.
Hounton and colleagues (2013) discuss how introducing a MDSR system can add value for policymaking and accountability and can build on existing efforts to conduct maternal death reviews, verbal autopsies and confidential enquiries. They go on to argue that accountability at national and sub-national levels cannot rely on global, regional and national retrospective estimates periodically generated from academia or United Nations organisations. MDSR is needed to improve accountability.
In a comment piece published in The Lancet Global Health, Bustreo and colleagues (2013) argue that as countries and international platforms engage in post-2015 planning, now is the time to envision the ending of preventable maternal deaths. They believe the global health community should build on past successes, and accelerate progress towards elimination of all preventable maternal mortality within a specified period. The collection of data about the causes and conditions of every maternal death through systems such as maternal death surveillance and response, is a necessary first step.