Last week, I attended a conference in Rabat entitled “Reducing Maternal Mortality in Morocco: Sharing Experiences and Sustaining Progress”. Morocco is one of the few developing countries that can legitimately argue that it is on track to achieve MDG5 – a three quarters reduction in maternal mortality from 1990 to 2015 – so I was very excited to get first hand knowledge of what I could learn from the Moroccan experience that could then be generalized to other countries.
In the early 1990s, the maternal mortality ratio (MMR) in Morocco was estimated in the vicinity of 330. According to the most estimates, the MMR in Morocco is now around 112 – which means that they have reduced their MMR by a whopping 60%! Much of the reduction has actually taken place during the past 5-7 years, coinciding with intensified efforts on the part of the government to reduce MMR. Given its trajectory, many people think that it will be able to go the rest of the way and actually achieve MDG5.
At this point I am sure a lot of you are thinking about measurement and data issues and whether or not we can actually say that Morocco has reduced its maternal mortality. This is a valid concern (and one which will plague all assessments of performance against MDG5) but all of the currently available sources of data on the MMR in Morocco seem to suggest that real declines have occurred: the UN Intra-Agency estimates, the IHME estimates (i.e. Hogan et al. 2010), and Morocco’s own estimate all point to similar trends.
So how did Morocco do it? After decades of incremental efforts there was a big shift in priority given to maternal mortality in 2008 when the government launched the ambitious strategy for accelerating reduction in maternal and child health (PARMMI). The strategy involves three major components: addressing physician and financial barriers, improving quality of care, and improving the management of governance of the programs themselves.
The government implemented just about every programmatic activity that has ever been thought to be effective using a “whole-of health-systems” approach: making obstetric care free, rolling out ambulances, training of health workers, increasing the number and distribution of health workers, implementing a mobile phone enable monitoring system, launching efforts to improve service quality, increasing awareness of the issues, and dramatically strengthening the information base available to the government to monitor progress. This last point also included a very intensive effort to track and audit all maternal deaths – a system one international expert called the “Cadillac” national maternal mortality surveillance system. They did it all and they did it quickly and effectively using resources from mainly the government but also from their development partners.
Given the number of interventions that were simultaneously launched it is difficult to tease out exactly what work, when, for whom, and why. The academic in me me wished there had been more evaluation of their experience and was left really wondering which interventions had been the most effective and why — but we we may never know.
But I did not leave the country disappointed as in the end I did learn why Morocco was able to achieve such a miraculous decline in maternal mortality: strong political commitment. During the conference the Minister of Health, a young woman not too much older than myself, stated that maternal mortality was the most important priority that her Ministry was attempting to address. So much so that victory for her was not achieving MDG5 but rather achieving an even lower MMR that she felt was more appropriate to their level of development. What sets Morocco apart from many other developing countries is the extent to which they have placed maternal mortality on the top of their list of priorities and have exerted significant effort and allocated substantial resources towards the issue. For maternal mortality, it seems that if there is a will, then there is a way.Share on Facebook