Preventing Maternal Mortality - A Yardstick for Social Justice


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I was glad to read the announcement made by World Bank President, Dr. Jim Kim, at the start of this year’s UN General Assembly meetings, about the Bank’s projected financing support through the end of 2015 to help developing countries reach the Millennium Development Goals (MDGs) for women and children’s health.  As we move toward the culmination of the MDGs in 2015 and beyond, preventing maternal and child deaths should be seen by all government delegations and their partners in the international development community as a clear yardstick to measure their commitment for creating more just and inclusive societies.

But as evidence has shown across the globe, to effectively address the insidiousness of this challenge, a broad multi-sectoral paradigm for action is needed.  In some countries, particularly in resource-poor settings and among certain population groups, there are social and cultural norms that need to be better understood to deal with myths and misconceptions surrounding pregnancy, childbirth and proper care of the newborn.  There are also geographical barriers, as in rural communities high in the Andean mountains of my native Ecuador, or in the Caucasus mountain range in Georgia and Azerbaijan, where the poor state of roads in a challenging terrain, or the unavailability of transport to a health facility, contribute to preventable maternal deaths.  

Since in most cases pregnancy complications cannot be predicted, a well-run health system organized around a care continuum—from prevention and diagnosis to care and rehabilitation, and without the hindrance of financial barriers to those in need, is an essential mechanism that needs to be in place to deal in a timely fashion with direct obstetric complications.  Such complications cause more than 60% of maternal deaths and include hemorrhage, hypertensive disease, sepsis/infection, and obstructed labor. 

What happens inside a health facility is of utmost importance in saving lives, beginning with the availability of trained and motivated staff to render needed services around the clock and essential drugs and blood products; adherence to basic quality standards, such as mandatory hand washing by doctors or nurses before patient examination; administration of safe blood transfusion in case of hemorrhage; and proper management of obstetrical and newborn complications such as eclampsia, asphyxia, and sepsis, which are often fatal if not promptly treated.  

The power of modern technologies can also be harnessed to improve maternal and child health.  As I recently learned in Ghana, an initiative by Mobile Technology for Community Health (MoTeCH) and the Grameen Foundation, piloted in the Upper East Region and now being replicated in the Central, Greater Accra and Volta Regions, is allowing women with limited literacy skills to be informed in the local language about the “do’s and don’ts” in pregnancy and childbirth. Women also receive reminders on clinical appointments, due dates, and required medication and immunization through their mobile phone.

This technology enables women, their partners and families, to recognize the signs of life-threating complications during pregnancy and empowers them to seek immediate care. Other applications allow community midwives and nurses to provide rapid response and care and to follow up with health service defaulters in the community.

Building upon agreements made at the 2012 London Summit on Family Planning, and  follow-on discussions expected in Addis Ababa in November 2013, added impetus should  be given to ensure well-funded and accessible voluntary family planning services as another essential but integrated tool to reduce unwanted pregnancies, unsafe abortions, and the risk of maternal death.

It is clear, as noted by Dr. Kim and colleagues in a recent article in The Lancet, that the end of extreme poverty will require sustained investments to improve health care delivery.  It should be obvious to all of us working in global development that a critical step toward that goal should be the revamping and acceleration of efforts to make maternal mortality a rare event, rather than a daily occurrence across the world. To paraphrase the great Nelson Mandela, the keener revelation of a society’s soul is how it treats its women and children.   



Patricio V. Marquez

Senior Associate, Johns Hopkins University Bloomberg School of Public Health

Albert Figueras
October 02, 2013

Good post, Patricio.
There is a lot of work to do in this area, and interventions should be planned in order to empower both health personnel and women trained as midwifes outside hospitals, and health professionals working in Obs&Gyn Services in hospitals.
In 2008 our group published the results of an educational intervention in different hospitals of Dominicana, Nicaragua, Guatemala, Perú and the NorthEast of Argentina. Just by involving health professionals in the review and rewording of their clinical guidelines greatly improve how preventive measures of postpartum haemorrhage were implemented.
In present days, we have enough knowledge to ensure a safe delivery and to prevent potential complications. Traditional manoevers are easy and preventive treatment (when necessary, in women with well-known risk factors) are cheap. The benefits for the mother, the baby (and his/hers brothers/sisters), the family and the community are enormous.
Kind regards.

October 05, 2013

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is actually remarkable.

Francoise Cluzeau
October 07, 2013

Thank you Patricio for this insightful blog. As you say, maternal and child health can improve significantly through introducing simple and inexpensive changes in practice such as mandatory hand washing and other safe obstetric practices to avoid complications; Quality standards derived from evidence-based guideline recommendations offer a practical mechanism for driving these changes especially if they are used in the context of well- structured and coherent health system with support from policy makers and professional organisations.
As an example, the Government of Kerala (Health & Family Welfare Department) is implementing a Quality Standard (QS) on improving maternity care in eight pilot hospitals in the state. This initiative is a partnership between the National Rural Health Mission (NRHM) and the Kerala Federation of Obstetricians and Gynaecologists (KFOG) who joined forces to develop the QS and to introduce it in practice. Using international evidence based guidelines (WHO, The National Institute for Health Care Excellence (NICE) and local clinical guidelines, the local consortium produced a document that covers key components of maternal care linked to improved outcomes, including active management of Third stage of labour, prevention and management of Post Partum Haemorrhage (PPH), pre eclampsia, placenta previa Accreta, hypertension, HELLP and eclampsia. The document includes measurable process and outcome indicators. A concerted approach was required to implement the QS. This included training, staff redeployment, procurement of equipment, establishing data collection and reporting systems. The pilot is ongoing until the end of March 2014. Monthly review meetings chaired by the NRHM Mission Director are held with the KFOG all the pilot sites reporting their data and experience.
NICE International provided technical assistance to the local team. The project has been reported in the Indian press at various stages.

Liselle Yorke
October 08, 2013

Dear Patricio:
Thank you for highlighting MOTECH's work in Ghana. I want to make one correction: the Ghana MOTECH initiative is a collaboration of Grameen Foundation and the Ghana Health Service.
Grameen Foundation has also expanded the MOTECH system that began in Ghana into a general-purpose platform that other organizations can deploy through the MOTECH Platform and the MOTECH Suite. The suite is a collaboration of Grameen Foundation, Dimagi, InSTEDD, OnMobile, OpenMRS, ThoughtWorks and University of Southern Maine.
Liselle Yorke
Grameen Foundation