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Millennium Goal 5
ETHICS/EDUCATION
Millennium Goal 5
The Millennium Development Goals
Anthony D Falconer
C C C
Abstract
C
Millennium Development Goal 5 incorporates targets related to improving maternal mortality in resource poor countries with universal access to reproductive healthcare. The complex interrelationship between causation and solution of these problems is expounded together with strategies of care. Healthcare modelling based on the provision of skilled birth attendants and emergency obstetric care facilities will reduce the terrible tragedy of maternal mortality. Currently 500,000 women die annually in childbirth, and the majority of these deaths are avoidable. The large majority occur in resource poor countries. With the current slow progress, it is unlikely that the necessary improvement will be achieved by 2015. Major initiatives aimed at education, increasing workforce and improving local facilities and availability of drugs will help. The solutions are simple, but progress requires political desire.
C C C C
1: 2: 3: 4: 5: 6: 7: 8:
Eradicate extreme poverty and hunger. Achieve universal primary education. Promote gender equality and empower women. Reduce child mortality. Improve maternal health. Combat HIV/AIDS, malaria and other diseases. Ensure environmental sustainability. Develop a Global Partnership for Development.
Box 1
Maternal death is further reflected in a tenfold increased death rate in the surviving children within two years of birth. Globally 500,000 mothers die through childbirth, 99% occurring in underresourced countries. The data from Sierra Leone suggest that 2100 women die per 100,000 live births (Table 1). The current data highlight the compounding influence of conflict within fragile states. What makes this statistic so alarming is the enormous contrast between the ‘haves and the have-nots’. Within the sophistication of westernized medicine the current maternal mortality rate in England and Wales is very low at 14/100,000. Such statistics introduce challenge and conflict. Reliability of data capture is real and mechanisms and methodology for obtaining such information are different in Sub-Saharan Africa (SSA). However, the consensus is that progress in MDG 5 has been very poor e maternal mortality rates have declined by less than 1% per year from 1990e2007. However, there are examples of significant change and improvement and such countries should act as role models. However, individual countries have individual challenges and one size does not fit all.
Introduction The millennium provided an imaginative opportunity for diverse projects at national and international level. For the UN, established to promote international cooperation and improve peace and stability, the Millennium Development Goals (Box 1) were designed to tackle aspects of inequalities in global provision. The framework for eight development goals focused on the stark differences in wealth, education, emancipation, service infrastructure and clinical outcomes for peoples in different parts of the world. MDGs 4, 5 and 6 included elements of healthcare, although the other MDGs included components on women’s rights, status and integrity, which are closely interlinked. In 1994, 179 countries committed to improving sexual and reproductive health and rights (SRHR) at the International Conference on Population and Development (ICPD). In effect these challenges were a statement of the unacceptable differences found in different corners of the world. The impact of the MDGs was reinforced through accompanying targets, which have focused both international and national thinking and planning. MDG 5A aimed to reduce by three quarters the maternal mortality ratio in 67 target countries, defined by a maternal mortality ratio of above 40/1000, by 2015. In addition MDG5B stipulated universal access to reproductive healthcare by 2015.
The aetiology of maternal mortality The causation of the majority of maternal deaths in underresourced communities reflects complications of five separate conditions e hypertension, obstructed labour, unsafe abortion, sepsis and most importantly haemorrhage, usually postpartum (Table 2). It is estimated that 90% of such deaths are avoidable given appropriate strategies and facilities for providing such care.
The magnitude of global maternal mortality
The Maternal Mortality Ratio and lifetime risk of death from pregnancy by region
The integrity of the family is central to most religions and cultures. Such stability, tragically, is threatened in many countries by the hazards of reproduction, where the life of the mother and newborn may be jeopardized by pregnancy. Currently one mother dies every minute from complications associated with reproduction and for every mother dying it is estimated that up to 20 will have major morbidity associated with the process.
Region Africa South East Asia Eastern Mediterranean Americas Western Pacific Europe
Anthony D Falconer FRCOG is President of the Royal College of Obstetricians and Gynaecologists, London, UK.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 20:12
MMR 900 450 420 99 82 27
Lifetime risk 23 74 61 420 680 2300
Table 1
369
Ó 2010 Elsevier Ltd. All rights reserved.
ETHICS/EDUCATION
For the majority of women in labour access to a skilled birth attendant with basic obstetric skills and equipment will improve outcome for mother and baby. In Africa only 46% of patients receive such care and within Asia the figure is 65%. In contrast, within Europe the figure is 99.5%. In addition, a population of 500,000 patients should have ready access to comprehensive obstetric care, blood transfusion and operative obstetrics including caesarean section. Further difficulties may be experienced through the three delays: delay in identifying a problem delay in transferring to a facility delay in appropriate action at the facility.
The five major causes of maternal death (%) within Africa and Asia Africa 34 10 9 4 4
Haemorrhage Sepsis Hypertension Obstruction to labour Complications of abortion
Asia 31 12 9 9 6
Table 2
Political implications of maternal death
15% of such complications develop unexpectedly and without appropriate interventions can become life threatening. These common obstetric emergencies are resolved easily in the majority of cases. The introduction of magnesium sulphate for the management of eclampsia and the correct administration of uterotonic agents following labour are two evidence-based lifesaving interventions.
For those of us working in the comfort of western medical models the solution to these problems seems easy. Such a simplistic analysis is unhelpful and imparting our own models on different communities may be harmful. Indeed, since the Millennium, the global financial collapse of 2008/9, the food shortages and the impact of global warming and climate change have all contributed to the challenge of MDG 5. The complex interconnected web of factors that might help resolve these issues includes political, economic, health service infrastructure, workforce, cultural and quality issues. At a global level, issues of maternal death have been lower priority than those claims for tackling HIV/AIDS and malaria and this has been reflected in lower donations. Within a country individual decisions will need to be made on strategic healthcare planning and funding. Indeed, planning along unified disease lines may be unhelpful. There is a symbiosis between MDGs 4, 5 and 6. Planning maternity provisions in the absence of cognizance for neonatal outcome is inappropriate. The complex interplay of cultural and religious factors may impact on maternal mortality. Negative attitudes to
Preventing maternal mortality MDG 5 includes universal access to family planning, availability of a skilled birth attendant at delivery and ready access to comprehensive obstetric care if and when required as the pillars of reproductive healthcare. The reality is very different and responsible for much of this tragedy. Unsafe abortion accounts for about 60,000 deaths per annum e one assumes that these reflect just the tip of the iceberg of unwanted pregnancies. Comprehensive and societal acceptance of family planning would reduce this figure considerably. Currently in SSA 24% of women have unmet family planning requirements. Adolescent pregnancy and close birth spacing compound the problem of maternal death.
Maternal mortality ratio 1930–1996 30
Per 1000 live births
25
Control of malaria Development of maternal care services Extension of trained maternal care services and improved accessibility Greater utilization of maternal care facilities Introduction of antibiotics
20
15
10
112 hospitals
Expansion of EmOC facilities Greater availability of skilled health manpower Greater utilization of skilled services
Establishment of the Family Health Bureau National maternal death review Improved quality of services Improved management
5 263 hospitals 0
30 34 38 42 46 50 54 58 62 66 70 74 78 82 86 90 94
Figure 1
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 20:12
370
Ó 2010 Elsevier Ltd. All rights reserved.
ETHICS/EDUCATION
Skilled birth attendance at delivery and maternal mortality ratio in Sri Lanka
MMR/100,000 live births
100
Skilled Birth Attendance at delivery
1800
90
1600
80
1400
70
1200
60
1000
50
800
40
600
30
400
SBA %
2000
20 Maternal Mortality Ratio
200
10
0
0 1935
1945
1955
1965
1975
1985
1995
2005
Year Figure 2
contraception and abortion may be adverse factors. Engaging with community and religious leaders may be advantageous and would appear to be an appropriate strategy. The development of a country and its sophistication may be accurately assessed by the infra structure of the health system. The components of a successful maternity system need a strong community midwifery component, providing antenatal, basic intrapartum care and postpartum care; a comprehensive facility within reach and a well-trained workforce providing quality care. In addition, a strong public health commitment responsible for quantificating change through maternal mortality review and improvement is vital. Different countries have produced results with different strategies.
providing such care, without the risk of staff disappearing as a result of the brain drain.
The challenge for 2015 Sadly, MDG 5 is further off-track than any of the other MDGs. Only 12 of the 68 identified countries seem on track. Advocacy has achieved much, but it cannot resolve the issue single handed. The challenge is to provide sustainable change focussing on workforce development and quality. The provision of buildings, roads, transport systems, medical agents and free care at the point of delivery, as in the NHS model would impact hugely. However, the quality of the care provided to the patient is fundamental. The intimacy of the care given by traditional birth attendants (TBAs) on a one-to-one basis in contrast to the care given by a harassed midwife or doctor working in an overcrowded facility may explain the reluctance of patients to move to such a unit. Like all good clinicians we should listen to our patients and try and provide what they require, so that they will avail themselves of such opportunities. A sustained commitment involving patients, civil societies, politicians and service providers will be required to address this issue. It behoves us all to assist creatively in any practical way to try and create the appropriate environment for success. A
Strategies of care Sri Lanka provides an illustration of success which has been achieved over 60 years with a political will to resolve the catastrophe of unacceptable maternal mortality (Figure 1). Such change reflects the provision of free education to tertiary level for all citizens independent of gender, together with a commitment to empowering women over matters of health. The second political initiative was to provide free healthcare for all. The critical health interventions included an expansion of health facilities guaranteeing access to community and complex care. Such a change included transportation issues. The expansion of midwifery was a major contributor to success (Figure 2). However, the commitment of political and medical leadership should not be discounted. Within the African context the challenges focus on workforce issues. In 1975, when Mozambique achieved independence the country was almost without any medical staff. Novel thinking was required to provide healthcare. The usual boundaries of professions, extolled in the West were broken down. A new cadre of medical staff was trained to perform interventional obstetric procedures including caesarean section. There is a realization that mid-level providers may be just as competent in
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 20:12
FURTHER READING Crisp N. Turning the world upside down e the search for global health in the 21st century. RSM Press, 2010. Falconer AD, Crisp N, Warwick C, Day-Stirk F. Scaling up human resources for women’s health. BJOG 2009; 116(suppl 1): 11e4. Pereira C, Cumbi A, Malalane R, et al. Meeting the need for emergency obstetric care in Mozambique: work performance and histories of medical doctors and assistant medical officers trained for surgery. BJOG 2007; 114: 1530e3. WHO. Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva: WHO, 2007.
371
Ó 2010 Elsevier Ltd. All rights reserved.
Millennium Goal 5
The Millennium Development Goals
Anthony D Falconer
C C C
Abstract
C
Millennium Development Goal 5 incorporates targets related to improving maternal mortality in resource poor countries with universal access to reproductive healthcare. The complex interrelationship between causation and solution of these problems is expounded together with strategies of care. Healthcare modelling based on the provision of skilled birth attendants and emergency obstetric care facilities will reduce the terrible tragedy of maternal mortality. Currently 500,000 women die annually in childbirth, and the majority of these deaths are avoidable. The large majority occur in resource poor countries. With the current slow progress, it is unlikely that the necessary improvement will be achieved by 2015. Major initiatives aimed at education, increasing workforce and improving local facilities and availability of drugs will help. The solutions are simple, but progress requires political desire.
C C C C
1: 2: 3: 4: 5: 6: 7: 8:
Eradicate extreme poverty and hunger. Achieve universal primary education. Promote gender equality and empower women. Reduce child mortality. Improve maternal health. Combat HIV/AIDS, malaria and other diseases. Ensure environmental sustainability. Develop a Global Partnership for Development.
Box 1
Maternal death is further reflected in a tenfold increased death rate in the surviving children within two years of birth. Globally 500,000 mothers die through childbirth, 99% occurring in underresourced countries. The data from Sierra Leone suggest that 2100 women die per 100,000 live births (Table 1). The current data highlight the compounding influence of conflict within fragile states. What makes this statistic so alarming is the enormous contrast between the ‘haves and the have-nots’. Within the sophistication of westernized medicine the current maternal mortality rate in England and Wales is very low at 14/100,000. Such statistics introduce challenge and conflict. Reliability of data capture is real and mechanisms and methodology for obtaining such information are different in Sub-Saharan Africa (SSA). However, the consensus is that progress in MDG 5 has been very poor e maternal mortality rates have declined by less than 1% per year from 1990e2007. However, there are examples of significant change and improvement and such countries should act as role models. However, individual countries have individual challenges and one size does not fit all.
Introduction The millennium provided an imaginative opportunity for diverse projects at national and international level. For the UN, established to promote international cooperation and improve peace and stability, the Millennium Development Goals (Box 1) were designed to tackle aspects of inequalities in global provision. The framework for eight development goals focused on the stark differences in wealth, education, emancipation, service infrastructure and clinical outcomes for peoples in different parts of the world. MDGs 4, 5 and 6 included elements of healthcare, although the other MDGs included components on women’s rights, status and integrity, which are closely interlinked. In 1994, 179 countries committed to improving sexual and reproductive health and rights (SRHR) at the International Conference on Population and Development (ICPD). In effect these challenges were a statement of the unacceptable differences found in different corners of the world. The impact of the MDGs was reinforced through accompanying targets, which have focused both international and national thinking and planning. MDG 5A aimed to reduce by three quarters the maternal mortality ratio in 67 target countries, defined by a maternal mortality ratio of above 40/1000, by 2015. In addition MDG5B stipulated universal access to reproductive healthcare by 2015.
The aetiology of maternal mortality The causation of the majority of maternal deaths in underresourced communities reflects complications of five separate conditions e hypertension, obstructed labour, unsafe abortion, sepsis and most importantly haemorrhage, usually postpartum (Table 2). It is estimated that 90% of such deaths are avoidable given appropriate strategies and facilities for providing such care.
The magnitude of global maternal mortality
The Maternal Mortality Ratio and lifetime risk of death from pregnancy by region
The integrity of the family is central to most religions and cultures. Such stability, tragically, is threatened in many countries by the hazards of reproduction, where the life of the mother and newborn may be jeopardized by pregnancy. Currently one mother dies every minute from complications associated with reproduction and for every mother dying it is estimated that up to 20 will have major morbidity associated with the process.
Region Africa South East Asia Eastern Mediterranean Americas Western Pacific Europe
Anthony D Falconer FRCOG is President of the Royal College of Obstetricians and Gynaecologists, London, UK.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 20:12
MMR 900 450 420 99 82 27
Lifetime risk 23 74 61 420 680 2300
Table 1
369
Ó 2010 Elsevier Ltd. All rights reserved.
ETHICS/EDUCATION
For the majority of women in labour access to a skilled birth attendant with basic obstetric skills and equipment will improve outcome for mother and baby. In Africa only 46% of patients receive such care and within Asia the figure is 65%. In contrast, within Europe the figure is 99.5%. In addition, a population of 500,000 patients should have ready access to comprehensive obstetric care, blood transfusion and operative obstetrics including caesarean section. Further difficulties may be experienced through the three delays: delay in identifying a problem delay in transferring to a facility delay in appropriate action at the facility.
The five major causes of maternal death (%) within Africa and Asia Africa 34 10 9 4 4
Haemorrhage Sepsis Hypertension Obstruction to labour Complications of abortion
Asia 31 12 9 9 6
Table 2
Political implications of maternal death
15% of such complications develop unexpectedly and without appropriate interventions can become life threatening. These common obstetric emergencies are resolved easily in the majority of cases. The introduction of magnesium sulphate for the management of eclampsia and the correct administration of uterotonic agents following labour are two evidence-based lifesaving interventions.
For those of us working in the comfort of western medical models the solution to these problems seems easy. Such a simplistic analysis is unhelpful and imparting our own models on different communities may be harmful. Indeed, since the Millennium, the global financial collapse of 2008/9, the food shortages and the impact of global warming and climate change have all contributed to the challenge of MDG 5. The complex interconnected web of factors that might help resolve these issues includes political, economic, health service infrastructure, workforce, cultural and quality issues. At a global level, issues of maternal death have been lower priority than those claims for tackling HIV/AIDS and malaria and this has been reflected in lower donations. Within a country individual decisions will need to be made on strategic healthcare planning and funding. Indeed, planning along unified disease lines may be unhelpful. There is a symbiosis between MDGs 4, 5 and 6. Planning maternity provisions in the absence of cognizance for neonatal outcome is inappropriate. The complex interplay of cultural and religious factors may impact on maternal mortality. Negative attitudes to
Preventing maternal mortality MDG 5 includes universal access to family planning, availability of a skilled birth attendant at delivery and ready access to comprehensive obstetric care if and when required as the pillars of reproductive healthcare. The reality is very different and responsible for much of this tragedy. Unsafe abortion accounts for about 60,000 deaths per annum e one assumes that these reflect just the tip of the iceberg of unwanted pregnancies. Comprehensive and societal acceptance of family planning would reduce this figure considerably. Currently in SSA 24% of women have unmet family planning requirements. Adolescent pregnancy and close birth spacing compound the problem of maternal death.
Maternal mortality ratio 1930–1996 30
Per 1000 live births
25
Control of malaria Development of maternal care services Extension of trained maternal care services and improved accessibility Greater utilization of maternal care facilities Introduction of antibiotics
20
15
10
112 hospitals
Expansion of EmOC facilities Greater availability of skilled health manpower Greater utilization of skilled services
Establishment of the Family Health Bureau National maternal death review Improved quality of services Improved management
5 263 hospitals 0
30 34 38 42 46 50 54 58 62 66 70 74 78 82 86 90 94
Figure 1
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 20:12
370
Ó 2010 Elsevier Ltd. All rights reserved.
ETHICS/EDUCATION
Skilled birth attendance at delivery and maternal mortality ratio in Sri Lanka
MMR/100,000 live births
100
Skilled Birth Attendance at delivery
1800
90
1600
80
1400
70
1200
60
1000
50
800
40
600
30
400
SBA %
2000
20 Maternal Mortality Ratio
200
10
0
0 1935
1945
1955
1965
1975
1985
1995
2005
Year Figure 2
contraception and abortion may be adverse factors. Engaging with community and religious leaders may be advantageous and would appear to be an appropriate strategy. The development of a country and its sophistication may be accurately assessed by the infra structure of the health system. The components of a successful maternity system need a strong community midwifery component, providing antenatal, basic intrapartum care and postpartum care; a comprehensive facility within reach and a well-trained workforce providing quality care. In addition, a strong public health commitment responsible for quantificating change through maternal mortality review and improvement is vital. Different countries have produced results with different strategies.
providing such care, without the risk of staff disappearing as a result of the brain drain.
The challenge for 2015 Sadly, MDG 5 is further off-track than any of the other MDGs. Only 12 of the 68 identified countries seem on track. Advocacy has achieved much, but it cannot resolve the issue single handed. The challenge is to provide sustainable change focussing on workforce development and quality. The provision of buildings, roads, transport systems, medical agents and free care at the point of delivery, as in the NHS model would impact hugely. However, the quality of the care provided to the patient is fundamental. The intimacy of the care given by traditional birth attendants (TBAs) on a one-to-one basis in contrast to the care given by a harassed midwife or doctor working in an overcrowded facility may explain the reluctance of patients to move to such a unit. Like all good clinicians we should listen to our patients and try and provide what they require, so that they will avail themselves of such opportunities. A sustained commitment involving patients, civil societies, politicians and service providers will be required to address this issue. It behoves us all to assist creatively in any practical way to try and create the appropriate environment for success. A
Strategies of care Sri Lanka provides an illustration of success which has been achieved over 60 years with a political will to resolve the catastrophe of unacceptable maternal mortality (Figure 1). Such change reflects the provision of free education to tertiary level for all citizens independent of gender, together with a commitment to empowering women over matters of health. The second political initiative was to provide free healthcare for all. The critical health interventions included an expansion of health facilities guaranteeing access to community and complex care. Such a change included transportation issues. The expansion of midwifery was a major contributor to success (Figure 2). However, the commitment of political and medical leadership should not be discounted. Within the African context the challenges focus on workforce issues. In 1975, when Mozambique achieved independence the country was almost without any medical staff. Novel thinking was required to provide healthcare. The usual boundaries of professions, extolled in the West were broken down. A new cadre of medical staff was trained to perform interventional obstetric procedures including caesarean section. There is a realization that mid-level providers may be just as competent in
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 20:12
FURTHER READING Crisp N. Turning the world upside down e the search for global health in the 21st century. RSM Press, 2010. Falconer AD, Crisp N, Warwick C, Day-Stirk F. Scaling up human resources for women’s health. BJOG 2009; 116(suppl 1): 11e4. Pereira C, Cumbi A, Malalane R, et al. Meeting the need for emergency obstetric care in Mozambique: work performance and histories of medical doctors and assistant medical officers trained for surgery. BJOG 2007; 114: 1530e3. WHO. Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva: WHO, 2007.
371
Ó 2010 Elsevier Ltd. All rights reserved.