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This weekend leaders of the G8 group of countries will gather in Muskoka in my home country to ponder their relevance in the world and to agree to a set of collective actions to help make the world a better place.  For those who are not familiar with it, Muskoka is kind of like the Hamptons except colder, with a lot less sand and a lot more black flies – a true Canadian paradise.  On the agenda, and of greatest interest to those in the global health community, will be discussion of “the Muskoka Initaitve” on maternal health.  Over the past few months there has been a lot said about what works in reducing maternal mortality – providing access to family planning, ensuring access to skilled assistance at delivery, and other solutions – but this is not the first time the international community has come together to address this issue and the solutions that are now being advocated are largely the same that have been advocated in the past.

So why is it that we still have seen so little progress?  As someone who tends to see the glass half empty, I thought I would leave what works to the experts and instead come up of my list of things that I believe do not work in reducing maternal mortality in hopes that such missteps are not repeated again.

1.  Making it all about abortion:  Few issues in global health generate as much debate as discussions of reproductive health, in particular whether family planning does or should include abortion.  While I believe that addressing the needs of women with unintentional or unwanted pregnancies is important to discussions of maternal mortality – whether through abortion or not – it is far from the most important issue.  I believe that when politicians in rich countries – all of which provide access to safe and legal abortion to their citizens – get in a room and fight about the appropriateness of safe and legal abortion abroad it distracts from other issues and it does little to advance the cause of poor women in developing countries.  Debates of this manner have happened in the past and have likely been part of the reason why progress on maternal mortality has stalled.  National forums are more appropriate venues for such discussions.  I doubt any rich nation country would want the G8 to convene a meeting to discuss whether or not they should be providing abortions in their respective countries.

2.  Looking for a magic bullet:  As I have recently discovered, bringing a new person into the world is a long, painful, and messy process that has more or less remained exactly the same for our entire existence as a species.  It is physical.  It involves lots of blood and strange bodily fluids.  It involves pushing a big thing through a much smaller thing.  There is not going to be a magic pill or pixie dust that will make this an easy and risk free process.  The interventions that are needed are going to be multifaceted and far more complicated than simply delivering a pill.

3.  Advocating for “low-cost” solutions only:  This is a another perennial favorite of the global health community.  I had seen the use of this language in earlier drafts of the G8 documents on maternal mortality, but I do not believe that it can be addressed without addressing health systems and this is not going to come cheap.  There are simply too few health care professionals available and the infrastructure needs are enormous in countries where maternal mortality has remained high.  However, “low-cost” should not be confused with “cost-effective” as there are likely to be many interventions that are potentially cost-effective, in particular when other non-targeted health outcomes are factored into the equation.

4.  Confounding addressing maternal health and child health issues: I suspect I will get criticized for this one by many readers, but I personally believe that the way in which maternal health issues have been lumped together with child health programs – aka MCH programs – has distracted attention away from maternal health programs.  Clearly these two health needs are related, but sometimes addressing the needs of women requires completely different kinds of programs, resources and relies on very different assumptions than addressing the needs of children.   What is good for the child is not always good for the mom.  Plus, it is easier to address the needs of children which may lead to those programs being prioritized over others.

5.  Setting grand and completely unrealistic targets:  Arguably the Millennium Development Goal 5 on maternal mortality was the most unrealistic goal among all of the MDGs.  To achieve such a reduction in maternal mortality it would have required record breaking annual declines every year from 1990-2015.  In my opinion, the only value from having set such an unrealistic goal is that it can now validly be argued that it is the goal towards which the least progress has been achieved.  Adequately scaling up the workforce, which will be essential to reduce maternal mortality, may take decades: training centers must be established, health care professionals must be trained, public sector workforce policies must be radically transformed.  Goals that are established must realistically reflect these needs.

So I will be watching with great enthusiasm this weekend as the G8 summit unfolds, and hope that something good comes out of it that will benefit the roughly 100 million women who give birth in the world every year.

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3 Responses to “What does not work in reducing maternal mortality”

  1. Simon Wright says:

    Is there not good evidence that complications from unsafe abortions are a significant cause of maternal mortality? One study said 37 deaths per 100,000 in sub-Saharan Africa. I agree very much on the ludicrousness of 7 men and one woman discussing what laws should apply in countries that did not elect them, but every opportunity which refers to all the causes of maternal mortality should be welcomed shouldn't it?

  2. Kathryn says:

    I am Canadian, and have been tearing my hair out over this particular drama. Your analysis is dead on. Thanks for articulating much better than I could what is wrong with this initiative.

  3. Karen Grepin says:

    Simon,

    Thanks for the comment. There have been some attempts to try to disaggregate overall estimated maternal mortality levels and ratios by specific causes, but I would not agree that there is "good" evidence. Overall our knowledge of maternal mortality is quite poor, so when it comes to digging deeper into these estimates and attributing maternal deaths to particular causes it is not surprising that these estimates are of even lower quality. In addition, the measurement of deaths attributed to abortion is further complicated by the fact that abortion is illegal in many of the countries where these deaths occur and therefore subject to reporting biases.

    The figure you mentioned of 37 deaths per 100,000 deaths is actually an interesting one and a good example of how poorly measured deaths due to abortion truly are. As far as I can tell, the figure stems from a 2006 paper by Carine Ronsmans et al (Lancet 2006; 368: 1189–200). To come up with this figure they took the overall maternal mortality ratio estimates from the 2004 WHO, UNICEF, UNFPA study and applied proportions estimated by another study that conducted a systematic review of maternal deaths by region (Lancet 2006; 367: 1066–74). Both studies are far from perfect, so when one multiplies one noisy estimate by another noisy estimate it is hard to say that this is another close to a precise estimate. That said, the of those exercises was not to come up with precise estimates but rather to give a ballpark estimates given that our data is so poor and should only be interpreted as such.

    But to go back to your comment – is it a significant cause of maternal mortality? Those same regional estimates suggest it was about 4% in sub-Saharan Africa, much lower hemorrhage, hypertensive disorders, sepsis, and even HIV/AIDS in this region. I don't know, is that a lot? Maybe. Admittedly, I think it might be among the most tractable given that legalizing the practice – something that can be done through a policy change – may do a lot to improve outcomes.

    But does debate at the international level lead to progress? I am not so sure. It seems that whenever this issue surfaces the political debate that ensues is so harmful to those politicians willing to take on the issue that few are willing to pursue it again. Perhaps that is why we have seen so little attention from the top policy makes to this issue in the past?

    Karen

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