In 1985, the late Allan Rosenfield published an articled entitled “Maternal Mortality – A Neglected Tragedy: Where is the M in MCH?“. It has a paper that has resonated well with me and sadly – over 20 years after its publication – it remains as true today.

Rosenfield argued that maternal and child health programs, despite the name, focus too little on the health of the mother (the M) but instead focus almost entirely on the delivery of a healthy baby (the C). While clearly this latter outcome is desired by all, it is important to realize that the health of the mother is itself a desirable outcome and it can also down the road influence the health of the child. I have frequently remarked that how we collect data on maternal and child health seems to be based on the idea that the pregnant woman are simply vessels to deliver a baby – and once the baby has arrived, it seems we care little if the vessel sinks.

Globally, almost a third of all maternal deaths are believed to be caused by post-partum hemorrhage (PPH) – a phenomenon that happens immediately after birth or what is known as the “third stage of labor”. My one paragraph understanding of the physiology is that the uterus is extremely well supplied with blood vessels. When a woman is pregnant her uterus needs to open up to accommodate the placenta. Contact with the placenta prevents bleeding (although imperfectly, this is a cause of bleeding during pregnancy). After delivery, the uterus contracts to expel the placenta. To prevent bleeding, it needs to fold back onto itself making contact with another part of the uterus. If something prevents proper contraction, the uterus may not fold back together properly leading to bleeding. Lots of it. So much that the mother may die if she does not receive immediate attention.

Once bleeding begins, the stuff she needs at that point is not the kind of stuff the midwives, traditional birth attendants, or community health extension workers cannot provide – she may need a blood transfusion to save her life – so having access to emergency obstetric care is key to prevent maternal mortality. This is one of the excuses as why it is so hard to reduce maternal mortality – it would involve such large expansions in highly specialized health workers and infrastructure.

However, while these health workers cannot do much once something goes wrong, they can do a lot to prevent PPH – hence supervision with a skilled attendant is key. Most of this can be done at relatively low cost. There is a standard set of practices following birth that together are known as the “active management of the third stage of labor (AMTSL)”. AMTSL includes controlled cord traction, uterine massage after delivery, and prompt clamping of the umbilical cord. Increasingly, the package also includes the use of a uterotonic drug (e.g. oxytocin). New research suggests that this last component can be extremely effective at reducing PPH and saving lives, but the rollout has been relatively slow.

A recent study of the use of oxytocin to prevent PPH in Vietnam, a country with moderate levels of maternal mortality, has demonstrated that the drug is effective and really cheap and cost-effective. The authors conclude:

“The low net incremental cost of AMTSL [with oxytocin] suggests that the introduction of AMTSL in primary-level facilities in Vietnam can reduce the incidence of PPH and benefit women’s health without adding much to national health care costs. In countries with scarce health care resources, where levels of PPH are generally much higher, AMTSL by either ampoule or Uniject device would likely be cost neutral, if not cost saving.”

Um, so we can save lives and maybe even save money? So why the heck aren’t we? Why are we not buying Starbucks Coffee and donating 5 cents to save the lives of women in Africa – because that is about as much as it would cost? Why is this not a bigger priority with donors? Why are countries themselves not paying for this technology? Why are women themselves not paying for it?

Part of it is that the intervention is a little tricky. The drug needs to be injected, so the midwives would need to be equipped and trained to inject the drug, and would need to ensure adequate supply of drugs and equipment, which could be a problem. There is a growing interest in using another drug, called misoprostol, which can be administered orally or vaginally reducing the need for additional equipment or supplies, but the drug is not as effective and might even be associated with some severe side effects. But I generally think the “its too complicated” argument is a bit lame. If we can get vaccines into the arms of nearly every child born in the world and can think about drawing blood for VCT testing in most parts of Africa, I think we can overcome this one as well. In the grand scheme of things, that seems solvable.

I think the bigger problem is that maternal big M issues are low on the radar of both national policy makers and international donors. Maternal health has not been successfully framed to us in such a way to make us want to invest. There have not been organizations that have successfully convinced us to do more and make this a real priority. So while we might be able to do a lot about this issue, we are not compelled to do so. The issue is not pressing enough.

There has been little progress towards achieving a reduction in maternal mortality in Africa – one of the MDGs. Good actionable interventions should continue to be evaluated and more effort should be made to ensure that the good ones get the attention they deserve. This might very well be one of them.

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3 Responses to “Improving outcomes for pregnant women — even after they give birth”

  1. Yael says:

    Hi Karen,
    I was wondering what your opinion is on a global fund for maternal health. I've read things both pro and con about it– do you think a global fund specifically created to equip hospitals and individuals to improve outcomes for pregnant women would be effective, or do you think it is too narrow of an approach?


  2. Karen Grepin says:


    Thanks for the comment and great question. Although I don't think it is an easy one to answer.

    I do believe that the only way to address this important issue is to make new investments in building up health infrastructure and increasing the proportion of birth supervised by trained attendants. There has not been nearly enough progress towards these indicators during the past few decades.

    But I am less convinced that a new "global fund" is the way to go about doing it. New ideas and new resources are going to be needed, but I tend to believe that resources are more effective and programs are more sustainable when they come from the affected communities themselves.

    Donors can help in this process, but I am not convinced that they should be leading the charge.


  3. Ben says:

    In addition to new investment in health infrastructure, there is good evidence that existing capacity is underutilized in the private sector of some developing countries and several studies have found that providing a demand side subsidy to patients, in conjunction with performance-based contracts for providers, can improve health outcomes. It is going to take both high quality healthcare supply and sufficient patient demand to improve maternal health.

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