The Lancet's Maternal Survival Series: An Urgent Call to Action

Each year, more than 500,000 women in the developing world die during pregnancy or childbirth: one in 16 women in Africa and 1 in 43 women in Asia will die of maternal causes this year, compared to 1 in 2,500 in the United States. The new Maternal Survival Series in the British medical journal The Lancet calls attention to the progress and the challenges of reducing maternal mortality in both the developing and the developed world, and outlines what the authors believe to be the "best bet" strategy for preventing these deaths. Series contributors and other maternal survival specialists gathered at the Wilson Center on October 5, 2006, to present a clear, consistent message that acting to save women's lives can and should be done. The event, organized by the U.S. Agency for International Development (USAID) and co-sponsored by the Global Health Initiative and the Environmental Change and Security Program, marked the U.S. launch of the series.

"It has been 20 years since we have made the commitment to safe motherhood; and we have come a long way, but definitely not far enough," said Dr. Harshad Sanghvi, JHPIEGO's medical director and event moderator. His sentiments were echoed by Mary Ellen Stanton, senior reproductive health adviser for USAID, who called for a reenergizing of health professionals "to combat the indifference" that allows women to die needlessly in childbirth. The Maternal Survival Series offers an opportunity to tackle indifference and build political will, said Dr. Nils Daulaire, president and CEO of the Global Health Council: "This is not simply an intellectual academic exercise, but a call to action that would carry with it real political momentum…. Over 10 million women have died since we first started talking about safe motherhood. Enough. It's well past time to act."

Making the Case for Mothers

"If you happen to be a woman born in sub-Saharan Africa, your lifetime risk of dying as a consequence of pregnancy or childbirth is 400 times that of your sister in the United States… This is simply not acceptable in a civilized world," said Daulaire. More than two decades ago the World Health Organization announced that half a million women were dying each year from obstetric complications; and the Lancet article "Maternal Mortality: A Neglected Tragedy. Where is the ‘M' in MCH?" asked why so little attention was paid to mothers in maternal and child health (MCH) programs. "The cost of inaction is devastating," said Ann Starrs, executive vice president of Family Care International, chair of the Global Partnership for Maternal and Newborn Health, and commentator in The Lancet series. She lauded the United Nations' 2006 decision to include reproductive health as a target of the Millennium Development Goals (MDG), an inclusion which will allow countries' progress on sexual and reproductive health and rights to be monitored through the MDG framework.

Anne Tinker, director of the Saving Newborn Lives Initiative at Save the Children, urged the health community to reach consensus on key advocacy messages, identify health champions, generate sustained resource commitment, build alliances, and exploit synergies. She also called for organizations to develop optimal strategies with childbirth as the nexus within a continuum of care, reach unity around technical interventions and strategies, and recognize key players who will bring different resources to the table. "We have two simultaneous challenges and should not settle for less…[We must] reach the current generation of vulnerable women and children," she said, and "build the infrastructure we've been talking about today to ensure that their younger sisters have better options ahead of them in the future years."

Moving Forward: The Health Center Strategy

The strategy developed by the Maternal Survival Series steering group—presented by Dr. Carine Ronsmans of the London School of Hygiene and Tropical Medicine and Marge Koblinsky of the International Centre for Diarrheal Diseases Research in Bangladesh–relies on scaling up and building new health centers to provide both emergency and non-emergency obstetric services, family planning, antenatal care, and safe abortions (where legal) to populations without adequate access to these services. In rural areas of developing countries, the speakers noted, only about one-third of women deliver in health centers. Their Lancet articles explain that access to health centers and skilled birth attendants is essential, and also demonstrate the feasibility of taking smaller, successful projects and implementing them on a larger scale.

Commentator Lynn Freedman, director of the Averting Maternal Death and Disability Program at Columbia University, applauded Ronsmans and Koblinsky's efforts to move beyond the epidemiological analysis of maternal health and focus on a few key strategies. However, Freedman pointed out a number of barriers to the health center approach, including lack of quality care, human resources, and the health centers themselves. Health centers, she said, must first and foremost exist; then, they must function, provide services, and do so in a respectful way. Freedman notes in her Lancet commentary, coauthored by Allen Rosenfield and Deborah Maine, that "programmes to reduce maternal mortality must be joined with bold efforts to overcome the steep systematic barriers to equitable access." A health center strategy that recognizes and confronts these barriers will "tackle fundamental health-systems problems in a focused, measurable, and pragmatic way—with implications well beyond maternal health."

Scarce Resources

Dr. Koki Agarwal, director of the ACCESS program at JHPIEGO, built on Freedman's statements and stressed the importance of human resources and resource mobilization. She drew from the research presented in The Lancet to demonstrate the financial and staffing obstacles to implementing the health center strategy: extending access to skilled care will require training 330,000 midwives, 140,000 community health workers, and 27,000 physicians by 2015. Also, she said, "An additional 1 billion dollars in 2006 would be needed to end this inequality." Although this is a challenge, Agarwal believes that "where there's a will there's a way," and urged governments to make commitments backed by resources. She also promoted empowering communities to better utilize available solutions, demand better services, pool resources for emergency transport, and be "more supportive" of maternal and newborn health care.

Audience members questioned the authors on the role of family planning in reducing maternal mortality, and questioned the feasibility of implementing this maternal health strategy in countries where childbirth traditionally takes place at home, like Ethiopia, where 90 - 95 percent of women deliver in their residences. The speakers agreed that extended services and more trained health workers are needed to increase the quality of—and attitude toward—services with a continued emphasis on family planning.

Daulaire, Freeman, Koblinsky, and Starrs concluded by saying that it may take a long time to roll out these types of systems in countries with very low levels of coverage. In the meantime, however, health professionals should set medium-term goals that will contribute to overall objectives. Stepping up institutional capacity of already established health centers, enabling them to provide good quality care, and increasing the demand for health centers is an urgent—and attainable—priority.

Drafted by Julie Doherty.

Webcast Order of Events:

9:30 a.m. - 9:35 a.m. – Opening Welcome

• Mary Ellen Stanton, U.S. Agency for International Development

9:35 a.m. - 9:40 a.m. – Setting the Stage

• Dr. Harshad Sanghvi, JHPIEGO

9:40 a.m. - 9:50 a.m. – Coming to Terms: Ending the Era of Neglect for the World's Mothers

• Dr. Nils Daulaire, Global Health Council

9:50 a.m. - 10:00 a.m. – History of the Global Safe Motherhood Initiative

• Ann Starrs, Family Care International

10:00 a.m. - 10:45 a.m. – Maternal Lancet Series Authors

• Dr. Carine Ronsmans, London School of Hygiene and Tropical Medicine;
• Marge Koblinsky, International Centre for Diarrheal Diseases Research, Bangladesh

10:45 a.m. – 11:05 a.m.: Responses

• Lynn P. Freedman, Columbia University
• Dr. Koki Agarwal, JHPIEGO

11:05 a.m. - 11:45 a.m.: Question & Answer

11:45 a.m. - 11:55 a.m.: The Way Forward

• Anne Tinker, Save the Children

11:55 a.m. - 12:00 p.m.: Closing

• Dr. Harshad Sanghvi, JHPIEGO