With only five years left until the 2015 deadline to achieve the Millennium Development Goals, one particular topic in transport that I believe should gather more collaboration and contributions from both the health and the transport sectors is the unfinished agenda of maternal and child health. The completion date of the MDGs is fast approaching but the discussions and research surrounding specific MDGs have been uneven. This is the case with MDG 4 and 5: Reduce the under-five mortality rate and improve maternal health.
Since our World Bank 2006 publication Maternal and Child Mortality Development Goals: What Can the Transport Sector Do? and the 2008 "Transportation for Health Workshop" little attention has been paid to moving the agenda forward and addressing the necessary next steps for improving the transportation and referral linkages for maternal health. Very seldom will I read a chilling story about the mortal dangers for women living in poverty who are ‘lucky’ or ‘unlucky’ to give birth (like this story in The Economist, June 24, 2010).
There are organizations that do very good work in trying to bridge the gap in providing vital transport services for accessing emergency and non-emergency health services (Transaid; Riders for Health) and research programs that have focused on better identifying knowledge gaps and examples of country good practice (Mobility&Health). These initiatives and our research done in this area have all identified that “in the case of death directly related to the distance between women’s homes and health-care centers, it is not only health-care institutions that should be examined, but also other factors such as infrastructure, transport and social services; all relevant governmental departments, not only health, should also be involved in tackling the problem” (World Health Organization. Health in the Millenium Development Goals. Geneva: WHO; 2005.)
However, scientific research on maternal mortality is focused mainly on clinical factors. Recent research has shown that overall, there is a lack of published information about the cultural and political determinants of maternal mortality. Research is also carried out by developed countries without the participation of researchers in the developing countries where maternal mortality was studied. Transport has been identified as one of the underreported factors of study as well, particularly in the context of the factors relevant for accessing health centers.
This spring, I attended an expert’s meeting organized by the Wilson Center's Global Health Initiative with their UNFPA funder and the Maternal Health Task Force that was extremely inspiring to me and it reignited this discussion, serving as a platform to identify the knowledge gaps and research questions needed to improve transportation and referral for maternal health. Representatives from India, Bolivia, and Ghana presented "case studies" on their unique transportation and referral experiences, which particularly resonated with me and demonstrated the complexity of referral systems and the need for increased funding for human resources, vehicle maintenance, supervision, and accountability.
The discussion also focused on transport efforts for newborns and infants. It was recognized that while babies are best transported in the ‘womb’ of the mother when emergencies do occur with newborns, they are often transported in a separate transport device – this was even discussed and recommended in our 2006 paper. However, there is now concurring evidence that “the urge to hastily transport such infants before starting intensive care should be discouraged, since infants, more so than most critical patients, tolerate transportation poorly if not appropriately prepared. The retrieval strategy involves speedy deployment of a neonatal intensive care team to the patient, stabilization and institution of intensive care and finally the transportation phase. Employing this approach will not only reduce the chance of clinical deterioration en route but, has been shown to improve the clinical condition of the baby during the trip.” This clearly bears implications for designing an emergency response to take intensive care to the baby rather than take the baby to intensive care ("Newborn Emergency Transport" by Andrew Berry).
Unfortunately, without more operational and country-based evidence, it appears unlikely that there will be a push for any major improvement in this area. Health systems' effectiveness is a strong topic but the link to transport and road access still does not appear to be a dominating factor for anticipating change in this area. As is the case with other issues, solving the multi-sectoral challenges and complexities for improving maternal health require some good analysis combined with an understanding of the local specificities as well as knowledge about at which point of the chain the transport sector or the health sector should intervene. There are also differences between urban and rural contexts.
One of the best evidence I came across about effective action in this area has been in Malaysia and Sri Lanka (Investing in Maternal Health. Learning from Malaysia and Sri Lanka). Despite differences in income levels and economic growth between Sri Lanka and Malaysia, both countries have been able to make significant reductions in their maternal mortality levels because they managed over time to expand service provision (particularly in rural areas); to increase utilization of services; and to emphasize quality of service as a last stage to ensure utilization. A key factor behind the declines experienced in both Malaysia and Sri Lanka was the planning of transport measures that linked with and supported the delivery of health services:
- Transport facilitated and improved access to health facilities to higher levels of health care whenhealth systems were underdeveloped in one location;
- Measures to stabilize the health condition of women with complications and the availability of blood supplies ensured successful transportation of patients to the next level of care;
- Early detection by midwives and nurses in rural health centers helped persuade patients to go to the hospital or brought patients to the nearest hospital where government transport was available;
- In both Malaysia and Sri Lanka, free or subsidized emergency transportation was provided in rural areas primarily; whereas ambulatory medical care was gradually and to a greater extent provided by the private sector and financed by user fees;
- In the absence of, or lack of access to an ambulance or other forms of official transportation (Sri Lanka evidence), field staff were authorized to hire private transportation for emergency referral. In this case, the money was reimbursed by the Ministry of Health – transport evolved from bullock cart or a buggy in remote areas to taxi or private vehicle;
- Telephone access also helped in referral process and efficiency of transport measures (Sri Lanka).
Recently, I have begun to develop my own simple theory about what could be fair for deciding on a strategy that works: the transport sector should be responsible for coordinating with the health sector up to the first level of care to ensure that there are good and passable roads as well as affordable services. After the first level of care, the health sector should be responsible for coordinating with the transport sector to purchase and maintain reliable and adequate transport emergency vehicles to move on and access good road networks. For rural areas in particular, it is also crucial that a catchment area for determining the location of a hospital actually be linked to a road as it is not enough just to build health clinics based on population density if there are no roads or vehicles to transport people to them. President Zoellick clearly agreed in his speech at the three-day UN summit of 140 leaders which started on Monday for stepping up efforts to meet the MDGs. Let’s hope this will help speed up the efforts to prevent women from dying in childbirth.