The Problem of Maternal Mortality in the Developing World - Literature review Example

Running Head: DISCUSSION PAPER: MATERNAL HEALTH DISCUSSION PAPER: MATERNAL HEALTH Name: Course: Institution: Date: Abstract Maternal death has been described as a shame that the world has yet to confront. Despite a global commitment to improve maternal health by reducing maternal mortality as reflected in the Millennium Development Goals, statistical evidence shows that the incidence of global maternal mortality is still high, especially in the developing world. What could account for the global failure to advance maternal health? There is sufficient evidence of what needs to be done to reduce maternal mortality and improve access to maternal health services. A review of the literature on maternal health indicates that there are various strategic approaches and policies which would be effective in reducing maternal mortality. However, what needs to be done is not being done in practice. The problem of maternal mortality in the developing world is being “over-medicalized” (overreliance on medical interventions) or tackled through strategies that emphasize on the medical approaches and solutions such as provision of obstetric emergency care. Coupled with structural inefficiencies such as lack of accountability and the inequity of access to delivery services in countries such as India, this reflects on the failure to advance maternal health. Introduction The fifth of the United Nation’s Millennium Development Goals (MDGs) is a commitment to improve global maternal health. This is to be realized through targeting as a primary outcome a three quarters reduction of the maternal mortality ratio by the year 2015 and as a secondary outcome universal access to reproductive health (Nanda, Switlick and Lule, 2005). As one of the MDGs, maternal health is therefore an issue of fundamental importance in improving the quality of life in developing countries. However, the realization of or current progress towards global improvement of maternal health in poor countries seems to have stalled as compared to developed countries. Indicators consistently confirm the reality that there have been failures to advance maternal, neonatal and child health globally. A stark indicator of the slow progress in advancing maternal health is the maternal mortality ratio in poor and developing countries. As the data available to policy makers becomes more accurate over the years, there is a realization that the problem had actually been underestimated. The incidence of maternal deaths in poor countries has been labeled “shameful” and “obscene”. The 2005 World Health Organization (WHO) Report indicated that approximately every minute, a woman dies from childbirth-related complications (WHO, 2005). The 2008 WHO Report also indicated that half of the women who gave birth in 2008 had no access to medical help during or after childbirth potentially endangering their lives (WHO, 2005). As further evidence of the failure to advance maternal health, maternal mortality ranks fourth among the leading causes of death for women worldwide behind HIV/AIDS, malaria and tuberculosis. In developing countries, pregnancy related complications are the leading cause of death and disability among women of reproductive age with 20 women suffering injury, infection or disease for every one that dies during or immediately after childbirth (Nanda Switlick and Lule, 2005). Common causes of maternal mortality include preeclampsia, eclampsia, obstetric hemorrhage, abruption and placenta previa (Borghi 2001). The seemingly depressing and endless streams of data and conclusions from these various reports do not, however, indicate a complete failure or retrogression. What they do indicate is a failure to advance or progress which is too slow to meet the MDG target. According to the WHO, meeting the target of a 75% global reduction by 2015 required a 5.5% annual decline in maternal and child mortality as compared to the actual 2.3% average annual decline globally (WHO, 2010). The rate of progress is therefore too slow; approximately half of what is required. Furthermore, the progress is driven by developing or high income countries with poorer or developing countries witnessing even slower rates of progress in combating maternal and child mortality. The abysmal “progress rate” or decline in maternal mortality shows that something is being done, but it is not sufficient. This raises a number of issues for consideration. What can explain the performance gap? Is it due to policy failures? What approaches have been used and what has been the outcome? This paper will examine past research into maternal and neonatal health and critically analyse the approaches employed in improving maternal health. In determining the possible causes of failure to advance maternal health globally, it will examine whether there is evidence of what needs to be done to improve maternal health and whether it is applied in practice. The paper will also highlight the theoretical and methodological developments in improving maternal health, highlight areas of convergence and disagreement and identify the possible gaps in implementing what needs to be done. By focusing on India, the paper will identify the challenges in implementing evidenced-based measures in developing countries. Is there evidence of what needs to be done? Research into the range of policy options available for improving maternal health have often focused on the reduction of maternal mortality (death) and disability in poor countries. Nanda, Switlick and Lule (2005) point out that in developing countries, the early strategies used to reduce maternal mortality focused on training midwives and traditional birth attendants (TBAs). This was based on the rationale that most maternal deaths in poor countries occur in a rural setting where there is limited or no access to quality medical and maternity services (Borghi 2001). TBA training programs were thus used to increase birth preparedness and provide community-based referral services for rural communities. However, the effectiveness or success of such programs in reducing maternal death was limited due to factors such as unforeseen obstetric emergencies. Bergstrom and Goodburn (2001) concur and argue that large scale TBA training programs should be given lower priority in tackling maternal morbidity and emphasis placed on developing obstetric and referral services The presence of skilled TBAs would count for little if obstetric emergency procedures such as caesarean section, placenta removal and surgery could not be performed on site (Graham et al 2001). As a response to the limitations of such interventions, the WHO launched the Safe Motherhood Initiative in 1987. The initiative aimed to raise awareness to the fact that pregnant women in developing countries were at risk and that it is important for them to access quality maternal health services which would help detect complications beforehand (Graham et al 1996). Safe motherhood initiatives Is there evidence on what needs to be done? Bergsjo (2001) studies the potential of antenatal care in reducing maternal mortality. According to Bergsjo, the provision of antenatal care should constitute a more viable approach to reducing maternal mortality than simply ensuring the presence of skilled attendants at the point of child delivery. Antenatal care would help in the detection of complications such as anemia and malaria which are leading causes of maternal deaths in developing countries. Campbell and Graham (2001) challenge the importance of antenatal care and argue that intrapartum care should be the main strategic priority in reducing maternal mortality. However, they recognize the importance of antenatal care and family planning in reducing maternal morbidity and argue that no single intervention could provide a universal solution. They propose a mix of country-specific strategic alternatives which target different sections of women. They argue that for instance, preventing unsafe and unwanted pregnancies is as effective a strategy as providing emergency obstetric care as it reduces the risk of unsafe induced abortions. On a country scale, Lerberghe and DeBrouwere (2001a) argue that the most effective strategies for reducing maternal mortality should be drawn from the success stories of developed countries which managed to halve their maternal mortality rates by professionalizing delivery care and investing in accessible safe hospital technologies such as ambulatory midwifes. While it is difficult to find fault in this logic, such strategies are not practically feasible for developing countries such as India with an overwhelming population. Professionalizing delivery care would require an enormous financial investment at the expense of other poverty-related priorities such as fighting hunger. Prata et al (2004) demonstrate the practical constraints involved in providing standardized delivery care in Tanzania, a low income country, that make professionalization economically unfeasible. They predict that a WHO safe motherhood initiative to provide standardized deliver care, Mother-Baby-Package (MBP), would not be able to recover its costs unless heavily subsidized. In the absence of subsidies, most households would have to spend more than half of their annual income on maternal care which would unduly burden poorer households. In essence, most households in poor countries would be unable to afford standardized or professional delivery care and would revert to the cheaper home delivery with its risks (Borghi, 2001). Significantly, Lerberghe and DeBrouwere (2001a) note that the decline in maternal deaths in industrialized countries is historically correlated with advancements in technology and increases in average income levels. The study by Campbell and Graham (2006) on what strategies work in reducing maternal mortality highlights the importance of addressing factors beyond the pregnancy itself in ensuring maternal survival. The evidence collected on what needs to be done seems endless. Campbell et al (1999) show that complications at childbirth could be result of physical and emotional abuse of the pregnant woman by their spouse. Therefore, screening for domestic violence could significantly lower the risk of maternal mortality in developing countries where domestic violence often goes unreported. This claim is independently supported by Murphy et al (2001) who relate complications in pregnancy such as premature labour, placental abruption or a ruptured uterus to the trauma caused by physical abuse from spouses. In addition, pregnant women who suffered abuse were found to be more vulnerable to using drugs such as nicotine and alcohol which increased the risk of maternal morbidity. Kolsteren and DeSouza (2001) point to the significance of diet in ensuring healthy maternal outcomes. Their paper provides evidence that deficiencies in nutrients such as calcium, magnesium and vitamins increase the risk of complications during pregnancy. Therefore, nutrition should be a vital component of programs aimed at reducing maternal mortality. On a legislative level, Thonneau (2001) urges for reform of abortion laws in developing countries to reduce the risk of maternal mortality due to unsafe abortions. Abortions account for approximately 19% of global maternal deaths (WHO, 2010). Due to the illegal status of abortion in many countries, many women resort to unsafe abortions from unqualified “quacks” with adverse medical consequences. Modifying abortion laws to allow for safer procedures would lower the risk of death or injury during such procedures. Economically, Chatterji and Markowitz (2004) provide evidence that longer maternity leave is correlated with better maternal health. Therefore, labour contracts should be restructured to allow for adequate maternity leave. However, most women in poor countries are often bound in demanding labour contracts with employers reluctant to grant them maternal leave. In their study of the maternal health situation in India, Vora et al (2009) point to the role of female literacy in accessing and utilizing maternal health services. The import of this that the utilization of maternal health services is correlated with levels of literacy and that pregnant women who are more informed are less vulnerable to maternal morbidity. This argument is supported by Kunst and Houweling (2001) who conclude that inequalities in utilization of delivery care are greater in countries with lower literacy rates especially in Sub-Saharan Africa and Latin America (Victora et al 2011). Therefore, universal access to free basic education contributes to the fight against maternal morbidity. What is being done? As earlier indicated, most of the effort towards reducing maternal mortality and realizing universal access to maternal health services in developing countries has been founded on the four pillars of safe motherhood. Particular attention has been paid to delivery of and improving the quality of antenatal, intrapartum and post partum care. The WHO and other international agencies have approached the maternal mortality problem by funding various safe motherhood initiatives such as provision of WHO standardized delivery care in Tanzania (Prata et al 2001: AbouZhar 2001). The strategic focus of such programs has been the provision of health center intrapartum care for pregnant women to encourage them to deliver in health centers with proximity to obstetric services and skilled birth attendants (Campbell, 2001). A survey of the literature on maternal mortality shows little if any evidence of policies and programs that recognize the cause and effect relationship between domestic abuse, the length of maternal leave, female literacy and abortion legislation and maternal mortality (). Instead, the focus is on what has been described as the “over-medicalization” of maternal care at the expense of evidence based strategies (Buekens 2001). These strategies prioritize the role of vaccination, family planning and other forms of antenatal and neonatal care in reducing maternal mortality. This indicates that the favored forms of intervention in developing countries targets shorter term solutions rather than addressing the comprehensive range of long term solutions as suggested by evidence. The strategic priorities preferred could account for the slow progress towards achieving the targeted reduction in maternal mortality rates. Despite of the various programmatic efforts used in a bid to reduce maternal mortality in India, cases of maternal deaths in India are still rampant. A number of factors can be attributed for the failures experienced in reducing maternal mortality in India. According to Vora et al (2009), the lack of focus on institutional deliveries is one of the possible causes of failures experienced in reducing maternal mortality in India. Vora et al observes that between 2004 and 2005, institutional deliveries in both public and private institutions were less than 40 %. Nevertheless, following the introduction of “Janani Suraksha Yojana”, a maternity benefit scheme, the number of institutional deliveries increased drastically. However, a good number of health institutions were unprepared for this change, plans to expand maternity facilities are yet to be realised. Consequently, most facilities face congestion, for instance in health facilities of Rajasthan , more than one woman share a single bed due to the increased demand of maternal services in health institutions (Vora et al, 2009). Challenges in implementing evidence based measures in developing countries- case study of India. There are various challenges in the implementation of evidence based strategies to reduce maternal mortality. Factors such as the lack of overall programme objectives, evidence based strategies and the lack of managerial capacity have been attributed to the failure of health programmes implemented in a bid to reduce maternal deaths in India (Graham et al 1996). For example, the operationalisation of the Child Survival and Safe Motherhood program (CSSM) and the Reproductive and Child Health 1 program (RCH 1) did not yield much result mainly due to government’s failure in planning and implementation of effective strategies (Vora et al, 2009).With regard to the CSSM programme the supply of health equipments was halted due to procedural and financial problems. Even after the equipments were supplied, they remained unused due to lack of motivation, training, maintenance and monitoring. On the other hand, the RCH 1 program introduced ground-breaking experimental solutions for long standing maternal problems. Nevertheless, instead of piloting these solutions on a small scale and then perfecting them before scaling, these solutions were applied vastly across. As a result uneven results were realized thus leading to the substantial failure of this programme (Vora et al, 2009). The absence of independent maternal health advocates in the civil society is also one of the possible causes for failures to reduce maternal mortality. In India, cases of maternal deaths have not been subjected to much socio-political debates this has in turn left room for complacency in health institutions. Members of legislative assemblies, judiciary and parliament have over the years ignored the increasing incidences of maternal mortality. NGO’s in India have actively rejected the introduction of implanted and injectable contraceptive. However, they have not played an active role in advocating for maternal health. Similarly, political leaders have also not played a proactive role in promoting reforms that would enhance maternal health (Shiffman & Ved, 2007). Significantly, the inequalities in access to maternal services have also contributed to the failure to reduce maternal mortality in developing countries. This is usually set against a backdrop where inter-regional and intra regional socio-economic inequalities determine the standard and quality of maternal services available to particular populations (Filippi et al 2006: Say and Raine 2007). This problem is particularly pervasive in countries like India with large populations spread over vast rural territories (Ramarao et al, 2001). Conclusion The WHO and other international agencies have provided statistical evidence which supports the conclusion that maternal health is still an issue of concern in developing countries. This evidence points towards a global failure in advancing maternal health. Ergo, progress towards achieving the fifth Millennium Development Goals appears to have stalled. This slow progress is despite the available evidence of what needs to be done to reduce maternal mortality rates in the developing world. A review of the literature suggests a variety of policy and technical interventions which would be effective in reducing maternal mortality. Reductions in maternal mortality can be achieved through approaches or initiatives which incorporate and address a variety of antenatal, intrapartum and postnatal issues. From a review of the literature on maternal health, various studies have revealed what needs to be done. For instance, Lerberghe and DeBrouwere (2001) argue that professionalization of delivery care would help reduce maternal mortality in developing countries as it has proven to work in industrialized countries. Campbell et al (1999) also demonstrate the potential for reducing maternal mortality by addressing issues of domestic violence or abuse. Kolsteren and DeSouza (2001) illustrate the role nutrition plays in reducing maternal mortality which suggests that programs targeting the reduction of maternal mortality should incorporate a nutritional component. Thonneau (2001) urges for reform of abortion laws in developing countries to reduce the risk of maternal mortality due to unsafe abortions. Chatterji and Markowitz (2004) provide evidence that longer maternity leave is correlated with better maternal health. Despite the evidence on what needs to be done, there still exist challenges in implementing effective evidence-based strategies in developing countries. A case study of India shows that some of the difficulties include a lack of political will to embrace adoption of evidence based programs coupled with inequalities in access to delivery care. The approaches and initiatives employed in practice are also limited to attacking the maternal mortality problem at the point of incidence such as training skilled attendants and providing emergency obstetric care. There is a clear lack of evidence to show programs which recognize the cause and effect relationships between education, nutrition and work conditions with maternal health. 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