OONA CAMPBELL: In this step, we’re going to be talking about strategies to reduce maternal mortality. Well, what should we do about the problem of maternal death? What skills, tests, and drugs do we need to routinely care for all mothers and newborns with respect and to prevent complications? But also, how do we detect complications and treat them appropriately? How might we organise services to provide such care? And what other strategies are needed to complement this? There are many single effective interventions that reduce maternal deaths, but there’s no one single intervention alone that can reduce all maternal deaths. So examples of routine interventions that all women should get include, for example, routine monitoring and management of labour.
And this is done using something called a partograph, but there are others as well. Examples of interventions, which a subset of women with complications should get, are many. But for example, one of them is magnesium sulphate, which is given when women have pre-eclampsia or eclampsia, and this is a condition that causes them sometimes to fit. Here I’m going to pause for a definition. In the maternal health field, we use the term Emergency Obstetric Care facility to describe a facility that can manage complications of pregnancy. And if you look on the obstetrics side, we normally look for eight signal functions.
Six of them are manual procedures and medical treatments, and two are surgery and blood transfusions, so the capacity to do caesarean section and provide blood transfusion. If a facility can do all eight signal functions, it’s normally termed a Comprehensive Emergency Obstetric Care facility. And this is normally what you would think of as a hospital. If it can only do the manual procedures and medical treatments, then normally we’d call that a Basic Emergency Obstetric Care facility. And that’s the kind of thing you might expect a health centre would be able to provide.
We talked about these single interventions, these drugs, treatments, and skills. But how do we actually make sure that women get that? And this is where we have to think about services and service delivery platforms. There are several main types. Some we can think about as being services to tackle unwanted pregnancy, and these include family planning and abortion services. And this is an area that’s touched on in some of the other steps. But we also have maternity services. And here it’s traditionally broken up into three types– antenatal care and screening, delivery care, and we can also think about postpartum care and general health services.
In this step, I’m going to focus on delivery care. Now, when we think about delivery, we can think about home deliveries. And this is usually, in fact, the absence of a health service. And usually home deliveries occur with an unskilled attendant. It can be a relative, or a traditional birth attendant, or a community health worker, or women can deliver alone. If complications arise in this situation, women need to obtain emergency obstetric care, usually by being transported to a suitable facility. If things are normal, then it’s OK. In facility care, women in labour make their way to a facility.
And this can be a lower-level facility like a health centre or a hospital, where they’re usually delivered by a skilled birth attendant, a midwife, or a doctor. If complications arise, women or their newborns will be managed with emergency obstetric care at the facility or transferred if necessary to a higher-level facility. If we’re in the situation where births are taking place at home without a skilled attendant, there’s some things that can be done to prevent or treat complications, but these are quite limited in their effectiveness. We can train traditional birth attendants, and this has been shown to improve referral and linkage to higher-level facilities when things go wrong.
We can also attempt home-based life saving skill training, where relatives are trained to recognise and manage basic things. But again, their efficacy is limited. Clean birth kits and misoprostol to prevent postpartum haemorrhage are also proposed as interventions.
In case of complications, if you have this kind of situation, it’s very important to avoid the three delays. The three delays model was proposed by Thaddeus and Maine. And it alerted us to the fact that if women were at home and things went wrong, we needed to reduce the amount of time taken to decide to seek care, for the family to identify and reach the right health facility. And then once they were in the facility, we needed to reduce the time taken to receive appropriate treatment. If these steps could be done, we could potentially prevent maternal death even if women were not in a place immediately where they could get care.
This is an example from work by Gabrysch in Zambia. And if you just look at the lower bar for the rural population, you can see that most of the population in Zambia, 7 million live in rural areas. And if you look at whether they’re close to any delivery service, you can see that around 80% are within 15 kilometres of a place where they can go to give birth. However, if we look at whether these places can actually provide basic emergency care, you can see that the proportion that are close to such a service drops down to 20%. So this is one of the problems with having home deliveries.
That if something goes wrong, many people are actually quite far away from some place that can manage even basic complications. In this kind of situation, what’s done to try to reduce the first and the second delay is birth preparedness, where we try to alert women to get them to prepare for what they would do if things go wrong, increasing awareness of danger signs, and also various transport schemes, both for routine labour and emergency. There are other approaches, too, that include maternity waiting homes, user fee removals and trying to reduce financial barriers, and task-shifting and referral as ways of trying to bring women closer to services. Here’s an example of the third delay.
Here we have two women who were admitted with a ruptured uterus in the Ivory Coast. And if you just look at the first woman, you can see this is a woman who was admitted in shock, and it took her over 10 hours to receive care. Most of that time was spent with the green and orange bits, where you can see time was spent to obtain the kit that was needed to do surgery to treat this woman. So huge delays even after women arrived at the facility.
Approaches that have been adopted to provide Emergency Obstetric Care within facilities, so to address the third delay, include pre-packaging complication kits so people don’t have to run around to prepare them, as in the first example. But also things like facility audits, life-saving skills, pre-service and in-service training with various competency-based approaches, and also other quality assurance mechanisms, such as drills and improving providers communication skills.
The main maternal health strategy in the Millennium Development Goal era was to try to ensure that all births took place with a skilled attendant. And this normally means in a health facility rather than having births taking place at home, particularly at home unattended or attended by an unskilled person. If we’re in health facilities, the focus should be on all births, most of which will be uncomplicated. And here we need efforts to support normality and to avoid disrespect and abuse and over-intervention. We also need to make sure that facilities have an enabling environment so that they can function but also provide the key signal functions for both routine care and emergency care if needed.
When we’re in facilities, we have some important questions. Are the providers really skilled? Have they actually been trained to do the things they need to do? Do facilities have the supplies, drugs, and equipment they need to provide care? Or are facilities overcrowded and under-staffed and without the right equipment? Are staffing levels sufficient? Is care respectful, evidence-based, and safeguarding of normality? Is there over-medicalization? Does referral from one level to another work? And are the costs affordable to women and their families, or are they catastrophic?
In summary, the best bet strategy needs to focus on monitoring women and their babies during labour and for 24 hours postpartum. Safety and primary prevention are key. But also, we need early detection and basic management of problems and treatment if it can be provided or referral elsewhere for emergency care. To support this best bet strategy, we need other strategies and approaches. And these include community participation and accountability, leadership and governance, health information systems, quality assurance systems, financing, and human resource training, deployment, retention, renumeration, motivation, and task-shifting.