maternalMortality 01As 2015 approaches, countries are focusing more of their attention on women's health and looking for new and innovative ways to meet the Millennium Development Goals (MDGs). Of the three health-related MDGs, progress has been slowest in attaining MDG5, which calls for a 75% reduction in maternal mortality and universal access to reproductive health. Recent estimates have shown some progress, but approximately 368,000 women still die annually and only 21 countries are on track to meet their maternal mortality goal. (lozano R, 2011) The risk of dying while giving life remains almost 100 times greater in the countries with the highest maternal mortality ratio compared to those with the lowest.

The editor of the medical journal the lancet summarizes the situation thus: "The apparent failure to reduce maternal mortality during 20 years of the Safe Motherhood movement has been one of the most deforming scars on the body of global health. Despite strong advocacy efforts, political leaders have either ignored the call or failed to make the health of women in pregnancy their priority." (Horton, 2010)

Such withering criticism has added pressure on political leaders to demonstrate their commitment through bold high profile investments in maternal health. Reducing the number of women who die during pregnancy requires a comprehensive health system that can deliver a continuum of care. (Kerber KJ, 2007) nevertheless, in many countries there is a propensity to focus on providing technologically advanced services as tangible proof of a health system's strength. More technology does not guarantee a better system, however, and in the case of Caesarean deliveries there is strong evidence for "too much of a good thing."

Even with excellent prenatal and perinatal care, sometimes a child must be delivered by urgent surgical intervention. The ability to safely perform a Caesarean is critical to reducing maternal mortality ratios. A recent analysis by the World Health Organization (WHO) confirmed this but also showed an apparent threshold rate above which Caesareans do not improve health; instead they contribute to additional maternal risk. (Betrán AP, 2007) One study in an industrialized European country showed that elective Caesarean deliveries (without medical cause) result in a risk of maternal death 2.84 times greater than vaginal birth. (Hall & Bewley, 1999)

The result of this dual effect is that health authorities are working to increase availability of Caesarean deliveries in low-income countries at the same time they are trying to decrease their use in middle and high-income countries. A survey conducted by WHO in 2005 showed average Caesarean rates among middle-income countries of 33%, the largest proportion of which were elective. The overall rate and the proportion of elective surgeries was greater in private clinics, suggesting that the procedure was offered more oft en when there were financial incentives to do so, rather than objective medical reasons. An analysis of these births clearly showed that Caesareans in the absence of medical indications resulted in increased maternal death and disability. (Villar, et al., 2006)

So what is the ideal Caesarean rate? As far back as 1985, WHO set a target Caesarean rate of no more than 10-15%. (World Health Organization, 1985) In 1997, a coalition of un agencies suggested that the Caesarean rate could be used as a proxy indicator for access to care for pregnant women. A rate below 5% was considered to be an indication of inadequate maternal care, while rates higher than 15% were considered to be excessive. (unICEF, WHO, unFPA, 1997) Since then, there has been considerable debate. (Peskin & Reine, 2002) (Editors, 1997) The discussion has been complicated by the fact that once a woman has a Caesarean, there is a risk of complications in subsequent pregnancies including uterine rupture. Experts at a 2006 U.S. national Institutes of Health (nIH) consensus conference avoided setting a target, concluding, "Optimal cesarean delivery rates will vary over time and across different populations according to individual and societal circumstances." (national Institutes of Health, 2006) nevertheless, even maternal health experts at the nIH express the sentiment that there are too many Caesarean deliveries performed worldwide, and the number is growing.

Maternal mortality rates in the U.S. have stagnated or even increased slightly over the last several decades, and there is a significant disparity among racial groups, with African- Americans having a rate approximately four times higher than the general population. (Geller SE, 2006) This has occurred in a setting with a high Caesarean rate, similar to other industrialized countries. In 1990, the U.S. set an ambitious goal of reducing the Caesarean rate to 15% by 2000. (U.S. Department of Health and Human Services, 2000) ultimately, they were unsuccessful and recently the government set a more modest goal of reducing Caesarean deliveries by 10% by 2020, which would decrease the national rate from 26.5% to 23.9%. (U.S. Department of Health and Human Services, 2011)

In both developed and developing countries, disparities in access to care require a stratified analysis of Caesarean rates. Virtually, in all low- and middle-income countries, there are significant rich/poor and urban/rural differences in the availability of Caesarean deliveries. (Ronsmans, Holtz, & Stanton, 2006) (Bhutta ZA, 2010) Women delivering in large urban hospitals, especially in middle-income countries, may undergo potentially unnecessary surgeries, while women in rural villages routinely die from preventable causes. In these instances, meaningful improvements in maternal mortality can only come from investing in a full system of care, including payment schemes to improve healthcare access for the poor and transportation and referral systems that allow physically remote and marginalized women to reach skilled birth-care while it is still possible to save their lives.

Donor countries are beginning to recognize the importance of strengthening health systems as opposed to focusing on specific interventions. The U.S. Global Health Initiative (GHI) has identified reducing maternal mortality as one of its core global health objectives. It is approaching this task by integrating maternal and child health into many of its existing health platforms, particularly the President's Emergency Plan for AIDS Relief (PEPFAR). In addition, it seeks to improve efficiency by enhancing country ownership of health programs and coordinating donor investments to maximize impact and reduce redundancy. This is particularly relevant during the current global economic downturn where public and private funding of health programs is under severe stress.

If political leaders committed themselves to improving access to family planning and maternal and child health services, they would reduce maternal deaths and also realize significant economic benefits. Simply meeting the unmet need for voluntary family planning would result in an estimated 66% reduction in unintended pregnancies, saving $5.1 billion that would otherwise be required to provide care to pregnant women and newborns. Another potential benefit is that unsafe abortions would decline by 73%, from 20 million to 5.5 million (assuming no change in abortion laws) and the number of women needing medical care for complications of unsafe procedures would decline from 8.5 million to 2 million.

Healthy women are also more economically productive and able to contribute to their communities. Investments in maternal and child health as well as the education of girls yield a critical "demographic dividend" that can add 1 to 2% to a country's Gross Domestic Product for 30 years or more. (Mason, 2005) ultimately, these investments can empower marginalized populations and lead to fundamental societal changes. It may be mere coincidence, but of the nine countries that are on track to meet Millennium Development Goal targets on both child mortality and maternal mortality, six are countries affected by recent social upheaval, including all of the countries that have ousted entrenched political regimes as part of the "Arab Spring". (lozano R, 2011)

There is no simple solution to reducing maternal mortality. It requires both investment in health infrastructure and attention to a range of socioeconomic factors. Technology- based solutions such as Caesarean deliveries are appealing, but they are only appropriate in specific circumstances. Although comprehensively addressing maternal health needs is complex and expensive, the moral and economic imperative of doing so is inescapable.



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