Since 2009, the “Advancing Dialogue on Maternal Health” series, co-produced by the Wilson Center, Harvard’s Maternal Health Task Force, and the United Nations Population Fund, has been one of the few public policy forums dedicated to maternal health.

Convening workshops in Washington, DC, India, and Kenya, the series has brought together experts, donors, program managers, and decision-makers from around the world to leverage their collective knowledge on reducing pregnancy-related deaths and complications. In total, the series has held 40 events over the last five years, with experts from around the world joining participants from the United States to showcase new research and discuss strategies for increased coordination in the field.

While the United Nations met in New York last month to discuss progress towards the Millennium Development Goals and begin designing their successors, the latest synthesis of the series’ recommendations was launched at the Wilson Center. The concurrence added a reflective tone to the conversation.

“I speak to you today with a sense of guarded optimism…maternal health is increasingly seen not as a specialty health issue, but rather as central to development,” said report co-author Margaret Greene. “What’s more, the principles that are key to maternal health echo at the heart of the post-2015 discussion, and vice-versa.”

Delivering Success: Scaling Up Solutions for Maternal Health highlights the progress made in reducing pregnancy-related deaths and injuries, building on the series’ first report, Delivering Solutions, while underscoring the significant work yet to be done.

Progress, But Inequalities and Corruption Continue

Since 1990, efforts by governments, NGOs, and private organizations have led to a reduction in global maternal mortality rates by almost 50 percent, said Greene.

In India, which accounts for one-fifth of all maternal deaths, pregnancy related mortalities plummeted from 480 per 100,000 women in 1995 to 200 per 100,000 in 2010. An increase in skilled attendants at birth was particularly important, said Poonam Muttreja, executive director of the Population Foundation of India. Between 1990 and 1993, only 33 percent of Indian mothers were seen by trained medical staff, compared to 53 percent between 2007 and 2008. “More and more pregnant women are offered at least minimal care,” she said.

“For the first time, it really feels like the elimination of preventable maternal deaths is an achievable goal,” said Jacquelyn Caglia of Maternal Health Task Force.

But as UNFPA Senior Advisor Geeta Lal cautioned, “much more remains to be done.” The rate of decline in maternal mortality is just over half of what is necessary to achieve Millennium Development Goal 5 – a 75 percent reduction in the maternal mortality ratio by 2015.

Macro and national-level data can be deceptive and mask disparities within countries. “Huge inequalities exist,” said Greene. “The most underserved communities and marginalized women remain unable to access the resources, information, and services to ensure safe pregnancy, delivery, and recovery.” The need to prioritize equity in health systems’ response to maternal health was one of the key findings discussed in the report.

An estimated 56,000 women still die every year in India from maternal health-related causes, and according to Muttreja, the disparity in care reaching the most marginalized women in society is a major reason why. Only 23 percent of mothers in the lowest wealth quintile receive any form of antenatal care, compared to 86 percent for women in the highest quintile, she said. In an investigation of 29 birth-related deaths in one hospital in the Barwani district of Madhya Pradesh, Muttreja said they found 26 of the women were tribals, India’s oldest indigenous people and some of the poorest ethnic groups.

Widespread corruption – surrounding both the procurement of drugs and the quality of service provided to women – is another issue common not only in India, but elsewhere, said Dr. H. Sudarshan, honorable secretary of Karuna Trust, who along with Muttreja helped organize a series workshop in New Delhi earlier this year. Women often must bribe doctors to receive pain-relieving drugs and other (technically) free services, he said. And in India, once a baby is born hospital employees may charge up to 250 rupees to allow family members to see the newborn.

Maternal morbidity is a third issue often overlooked. Though there has been much research on mortality, the prevalence of crippling injuries and disease among pregnant mothers has been the topic of just two studies in India, said Muttreja. “For every woman who dies, many more suffer from severe psychological, emotional, and mental stress,” she said. “The maternal mortality agenda is incomplete without a maternal morbidity agenda.”

Leveraging Technology

To address these deficiencies, development experts are harnessing emerging technologies in innovative ways. For example, in partnership with the central government, the Population Foundation of India will launch a television series in January integrating messages about maternal health and women’s empowerment, said Muttreja.

Modeled after South Africa’s popular Soul City soap opera, which promotes public health, the Indian version will similarly leverage mass media to disseminate narratives showing lifesaving behavior and empowered women. Collaborating with the government will allow them to air the show for free nationwide and, combined with efforts to translate it into several languages, they expect to reach 80 percent of Indians and 20 percent of the country’s poorest women, said Muttreja. Translated from Hindi, the show title, Main Kuch Bhi Kar Sakti Hoon, means, “I can do anything,” and uses the female verb tense.

Another project, developed by the United Nations Population Fund and Intel, is a series of interactive, online and mobile-accessible modules that teach users the causes and symptoms of pregnancy-related injury and death. According to Lal, four modules have already been created, focusing on preeclampsia/eclampsia, post-partum hemorrhage, obstructed labor, and post-abortion care. “We know that technology is spreading faster than we can blink,” Lal said. “With five billion mobile [phone] users – of which 4.5 billion are in the developing world – it’s an opportunity that we cannot ignore anymore.”

Data Collection and More Ethical Treatment

The success of technology-driven initiatives, however, relies on the collection of accurate data. Without it, decision-makers are unable to pinpoint gaps in quality and access, and thus unable to design effective interventions in response. As such, the report emphasizes the need to improve methods of data collection and management, said Greene.

“Data really are our building blocks, and they’re the building blocks on which we can accomplish our goals,” echoed Caglia. “We need better systems of measurements related to maternal and newborn health outcomes.”

The recommendations of Delivering Success, the culmination of the “Advancing Dialogue on Maternal Health” series’ work over the last two years, come as debate about the post-2015 development agenda heats up. What role will maternal health play in the MDG successors? How can policymakers and practitioners build on existing momentum and fill stubborn gaps in coverage?

According to Lal, improvement in health care quality, equality, and accountability must continue to be emphasized as strategic priorities. Ensuring that health workers and policymakers are trained in the principals of respect, business ethics, and non-discrimination cultivates a healthy sense of entitlement among beneficiaries, said Greene, which in turn creates greater accountability as people demand their rights.

“I feel good governance in health care can give a quantum jump in health outcomes, especially maternal health,” concluded Sudarshan.

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