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The challenge of meeting the Millennium Development Goal for maternal health
International Journal of Gynecology and Obstetrics (2008) 102, 1–2
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
w w w. e l s e v i e r. c o m / l o c a t e / i j g o
SPECIAL EDITORIAL
The challenge of meeting the Millennium Development Goal for maternal health
Richard Adanu, M.D. University of Ghana Medical School Accra, Ghana Dr Richard Adanu is a Senior Lecturer and Consultant obstetrician/gynecologist at the University of Ghana Medical School. He received his medical education and postgraduate training in obstetrics and gynecology in Ghana. He later obtained an MPH degree from the Johns Hopkins Bloomberg School of Public Health, USA, as a Gates scholar. Dr Adanu lectures in obstetrics, gynecology, demography, and reproductive health. He has been an Associate Editor of the Contemporary Issues in Women's Health section of the International Journal of Gynecology and Obstetrics since 2005 and also serves on the Editorial Board. Dr Adanu is involved in research in the epidemiology of obstetric and gynecological conditions in Ghana, family planning, cervical cancer screening, and maternal birth injuries. The Millennium Development Goals (MDGs) were agreed by world leaders as a measure to determine the progress of a nation between 1990 and 2015. The inclusion of MDG 5–to improve women's health–was welcomed by advocates of women's health and safe motherhood. The target of MDG 5 is to reduce maternal mortality by 75% between 1990 and 2015.
The main strategy to achieve this goal is to ensure that 90% of all births are attended by a skilled attendant in 2015 [1]. A skilled attendant is defined as “an accredited health professional–such as a midwife, doctor or nurse–who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns” [1]. Estimates for 2005 indicate that 63% of all deliveries are conducted by skilled attendants [2]. The figure for high-income nations is 99%, while for low-income nations it is 59% [2]. Over 90% of maternal deaths occur in these low-income nations [3]. Maternal mortality is the health indicator that shows the greatest disparity between low- and high-income nations. High-income nations are reported to have a combined maternal mortality ratio of 9 per 100,000 live births, while the corresponding figure for low-income nations is 450 per 100,000 live births [3]. However, the successes in reducing maternal mortality in Sri Lanka and Malaysia suggest that remarkable achievements can be made even in low-income nations with limited resources. A recent analysis of the trends in maternal mortality showed that maternal deaths need to decline by 5.5% per annum between 1990 and 2015 to achieve MDG 5 [3]. However, the decline has been less than 1% per annum between 1990 and 2005 [3]. We are less than 10 years away from 2015 and faced with the challenge of achieving MDG 5. After assessing the efforts made over the past 20 years to research and reduce maternal mortality, Rosenfield et al. [4] stated that we now know where the “M” is in “MCH” [maternal and child health] but what we need today is the determination and resources to take the steps to reduce maternal mortality. Professional organizations involved in maternal healthcare need to engage with political leaders in low-income nations to impress upon them the tragedy of maternal mortality. However, this engagement should be made by nationals of the countries and not by representatives of international organizations. We need to be able to tell our leaders the stories of the women they represent in government in a way that demands their attention. Countries need to publicly declare maternal mortality reduction as a
0020-7292/$ - see front matter © 2008 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2008.03.011
2 national priority before any meaningful strides can be made. It is one thing to agree and sign up to the MDGs and quite another to voluntarily declare that one's nation should work toward achieving these goals. Without significant money pledged from national budgets toward reducing maternal mortality, the target set in MDG 5 will not be achieved. This is because it requires major national commitment to continue to train skilled attendants, and to provide what is needed after training to retain the skilled attendants in their countries of origin. The availability of skilled attendants to conduct deliveries does not necessarily mean that their services will be used. Health financing systems must be analyzed so that women have financial access to these skilled attendants. It is well known that the poorest people are the ones hurt most by user fees. It is also known that in almost all countries where maternal mortality ratios are low, people do not pay for health services at the service delivery point; the services are either free or are covered by a good health insurance system. The issue of geographic access also needs to be tackled. Communities should be encouraged to design sustainable transport facilities that are readily available throughout the day to transport pregnant women who need emergency obstetric care. However, this should be recognized by governments as a “stop-gap” measure until roads and emergency transport services are implemented. Maternal mortality is a peculiar public health problem because it requires a good amount of clinical input to solve it. Major lessons learned over time show us that obstetric complications cannot be predicted in most cases, and that some complications are unpreventable. The good news, however, is that most maternal deaths are preventable with appropriate treatment. The treatment of these obstetric complications is only possible when skilled attendants have the appropriate facilities to work in and a regular supply of the appropriate materials and medication. National governments must be committed to the regular supply of these resources to save women from needless deaths.
SPECIAL EDITORIAL The goal to reduce maternal mortality to 75% of the level in 1990 within the next 8 years might appear lofty, but the existing evidence shows that “maternal mortality can be halved in developing countries every 7–10 years … regardless of income level and growth rate” [4]. If we are unable to achieve the target, but are successful in ensuring that the majority of governments in low-income nations voluntarily place the reduction of maternal mortality as a priority on their political manifestos, we will have taken a major step toward improving maternal health. National groups need to take up the challenge now. The international community has put maternal mortality on the world's agenda; let us now take the steps to ensure that maternal mortality is a major item in the political dialogue of our nations.
References [1] World Health Organization. Making pregnancy safer: the critical role of the skilled attendant. A joint statement by WHO, ICM and FIGO. Geneva: World Health Organization; 2004. p. 1–2. [2] World Health Organization. Skilled attendant at birth: 2005 estimates. Available at www.who.int/reproductive-health/ global_monitoring/skilled_attendant.html. [3] World Health Organization. Maternal mortality in 2005. Estimates developed by WHO, UNICEF, UNFPA, and the World Bank. Geneva: World Health Organization; 2007. [4] Rosenfield A, Maine D, Freedman L. Meeting MDG-5: an impossible dream? Lancet 2006;368:1133–5.
Richard Adanu University of Ghana Medical School, Accra, Ghana E-mail addresses: [email protected]; [email protected].
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
w w w. e l s e v i e r. c o m / l o c a t e / i j g o
SPECIAL EDITORIAL
The challenge of meeting the Millennium Development Goal for maternal health
Richard Adanu, M.D. University of Ghana Medical School Accra, Ghana Dr Richard Adanu is a Senior Lecturer and Consultant obstetrician/gynecologist at the University of Ghana Medical School. He received his medical education and postgraduate training in obstetrics and gynecology in Ghana. He later obtained an MPH degree from the Johns Hopkins Bloomberg School of Public Health, USA, as a Gates scholar. Dr Adanu lectures in obstetrics, gynecology, demography, and reproductive health. He has been an Associate Editor of the Contemporary Issues in Women's Health section of the International Journal of Gynecology and Obstetrics since 2005 and also serves on the Editorial Board. Dr Adanu is involved in research in the epidemiology of obstetric and gynecological conditions in Ghana, family planning, cervical cancer screening, and maternal birth injuries. The Millennium Development Goals (MDGs) were agreed by world leaders as a measure to determine the progress of a nation between 1990 and 2015. The inclusion of MDG 5–to improve women's health–was welcomed by advocates of women's health and safe motherhood. The target of MDG 5 is to reduce maternal mortality by 75% between 1990 and 2015.
The main strategy to achieve this goal is to ensure that 90% of all births are attended by a skilled attendant in 2015 [1]. A skilled attendant is defined as “an accredited health professional–such as a midwife, doctor or nurse–who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns” [1]. Estimates for 2005 indicate that 63% of all deliveries are conducted by skilled attendants [2]. The figure for high-income nations is 99%, while for low-income nations it is 59% [2]. Over 90% of maternal deaths occur in these low-income nations [3]. Maternal mortality is the health indicator that shows the greatest disparity between low- and high-income nations. High-income nations are reported to have a combined maternal mortality ratio of 9 per 100,000 live births, while the corresponding figure for low-income nations is 450 per 100,000 live births [3]. However, the successes in reducing maternal mortality in Sri Lanka and Malaysia suggest that remarkable achievements can be made even in low-income nations with limited resources. A recent analysis of the trends in maternal mortality showed that maternal deaths need to decline by 5.5% per annum between 1990 and 2015 to achieve MDG 5 [3]. However, the decline has been less than 1% per annum between 1990 and 2005 [3]. We are less than 10 years away from 2015 and faced with the challenge of achieving MDG 5. After assessing the efforts made over the past 20 years to research and reduce maternal mortality, Rosenfield et al. [4] stated that we now know where the “M” is in “MCH” [maternal and child health] but what we need today is the determination and resources to take the steps to reduce maternal mortality. Professional organizations involved in maternal healthcare need to engage with political leaders in low-income nations to impress upon them the tragedy of maternal mortality. However, this engagement should be made by nationals of the countries and not by representatives of international organizations. We need to be able to tell our leaders the stories of the women they represent in government in a way that demands their attention. Countries need to publicly declare maternal mortality reduction as a
0020-7292/$ - see front matter © 2008 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2008.03.011
2 national priority before any meaningful strides can be made. It is one thing to agree and sign up to the MDGs and quite another to voluntarily declare that one's nation should work toward achieving these goals. Without significant money pledged from national budgets toward reducing maternal mortality, the target set in MDG 5 will not be achieved. This is because it requires major national commitment to continue to train skilled attendants, and to provide what is needed after training to retain the skilled attendants in their countries of origin. The availability of skilled attendants to conduct deliveries does not necessarily mean that their services will be used. Health financing systems must be analyzed so that women have financial access to these skilled attendants. It is well known that the poorest people are the ones hurt most by user fees. It is also known that in almost all countries where maternal mortality ratios are low, people do not pay for health services at the service delivery point; the services are either free or are covered by a good health insurance system. The issue of geographic access also needs to be tackled. Communities should be encouraged to design sustainable transport facilities that are readily available throughout the day to transport pregnant women who need emergency obstetric care. However, this should be recognized by governments as a “stop-gap” measure until roads and emergency transport services are implemented. Maternal mortality is a peculiar public health problem because it requires a good amount of clinical input to solve it. Major lessons learned over time show us that obstetric complications cannot be predicted in most cases, and that some complications are unpreventable. The good news, however, is that most maternal deaths are preventable with appropriate treatment. The treatment of these obstetric complications is only possible when skilled attendants have the appropriate facilities to work in and a regular supply of the appropriate materials and medication. National governments must be committed to the regular supply of these resources to save women from needless deaths.
SPECIAL EDITORIAL The goal to reduce maternal mortality to 75% of the level in 1990 within the next 8 years might appear lofty, but the existing evidence shows that “maternal mortality can be halved in developing countries every 7–10 years … regardless of income level and growth rate” [4]. If we are unable to achieve the target, but are successful in ensuring that the majority of governments in low-income nations voluntarily place the reduction of maternal mortality as a priority on their political manifestos, we will have taken a major step toward improving maternal health. National groups need to take up the challenge now. The international community has put maternal mortality on the world's agenda; let us now take the steps to ensure that maternal mortality is a major item in the political dialogue of our nations.
References [1] World Health Organization. Making pregnancy safer: the critical role of the skilled attendant. A joint statement by WHO, ICM and FIGO. Geneva: World Health Organization; 2004. p. 1–2. [2] World Health Organization. Skilled attendant at birth: 2005 estimates. Available at www.who.int/reproductive-health/ global_monitoring/skilled_attendant.html. [3] World Health Organization. Maternal mortality in 2005. Estimates developed by WHO, UNICEF, UNFPA, and the World Bank. Geneva: World Health Organization; 2007. [4] Rosenfield A, Maine D, Freedman L. Meeting MDG-5: an impossible dream? Lancet 2006;368:1133–5.
Richard Adanu University of Ghana Medical School, Accra, Ghana E-mail addresses: [email protected]; [email protected].