Reducing maternal mortality in the developing world: sector-wide approaches may be the key

Maternal mortality in the covid-19 pandemic: findings from a rapid systematic review

BACKGROUND

The COVID-19 pandemic is having significant direct and associated effects on many health outcomes, including maternal mortality. As a useful marker of healthcare system functionality, trends in maternal mortality provide a lens to gauge impact and inform mitigation strategies.

OBJECTIVE

To report the findings of a rapid systematic review of studies on levels of maternal mortality before and during the COVID-19 pandemic.

METHODS

We systematically searched for studies on the 1st March 2021 in MEDLINE and Embase, with additional studies identified through MedRxiv and searches of key websites. We included studies that reported levels of mortality in pregnant and postpartum women in time-periods pre- and during the COVID-19 pandemic. The maternal mortality ratio was calculated for each study as well as the excess mortality.

RESULTS

The search yielded 3411 references, of which five studies were included in the review alongside two studies identified from grey literature searches. Five studies used data from national health information systems or death registries (Mexico, Peru, Uganda, South Africa, and Kenya), and two studies from India were record reviews from health facilities. There were increased levels of maternal mortality documented in all studies; however, there was only statistical evidence for a difference in maternal mortality in the COVID-19 era for four of these. Excess maternal mortality ranged from 8.5% in Kenya to 61.5% in Uganda.

CONCLUSIONS

Measuring maternal mortality in pandemics presents many challenges, but also essential opportunities to understand and ameliorate adverse impact both for women and their newborns. Our systematic review shows a dearth of studies giving reliable information on levels of maternal mortality, and we call for increased and more systematic reporting of this largely preventable outcome. The findings help to highlight four measurement-related issues which are priorities for continuing research and development.

Factors associated with postcesarean blood transfusion: a case control study

Objective: Cesarean delivery (CD) is a known risk factor for postpartum hemorrhage. However, the characteristics associated with post-CD transfusion are not well-established. We aimed to assess blood transfusion rates and associated factors following CD.Methods: A retrospective case-control study of women who underwent CD at a university hospital. The study group comprised all women who received blood transfusion following surgery. A control group of women who did not receive postoperative blood transfusion was assigned in a two-to-one ratio.Results: During study period, the overall post-CD blood transfusion rate was 4.7%. The study group comprised 170 women, and the control group 340. Maternal age (aOR [95% CI]: 1.07 (1.03, 1.11), p = .001), parity (aOR [95% CI]: 1.26 (1.09, 1.47), p = .002), gestational hypertensive disorders (aOR [95% CI]: 4.07 (1.52, 10.91), p = .005), maternal comorbidities (aOR [95% CI]: 4.16 (1.88, 9.1), p < .001), lower predelivery hemoglobin level (aOR [95% CI]: 0.43 (0.34, 0.54), p < .001), and major placental abnormalities (aOR [95% CI]: 2.74 (1.04, 7.18), p = .04) were independently associated with blood transfusion requirement. Intrapartum characteristics associated with blood transfusion requirement included nonelective procedure (aOR [95% CI]: 3.21 (1.72, 5.99), p < .001), prolonged second stage of labor (aOR [95% CI]: 5.50 (2.57, 11.78), p < .001), longer duration of surgery (aOR [95% CI]: 1.03 (1.02, 1.04), p < .001), general anesthesia (aOR [95% CI]: 2.11 (1.14, 3.91), p = .02), and greater estimated operative blood loss (aOR [95% CI]: 5.72 (3.15, 10.36), p < .001).Conclusions: Among women who underwent CD, we identified 11 factors associated with blood transfusion following surgery. Prospective studies are warranted to assess the implementations of prophylactic interventions to reduce transfusion rates among those deemed at high risk for CD-related bleeding.

"Morir En Camino": Community Narratives about Childbirth Care in Rural Chiapas

This anthropological study explores why more women in the rural Sierra Madre region of Chiapas, Mexico birth at home rather than at the hospital. Between January and May of 2014, the primary investigator conducted in-depth, semi-structured interviews with twenty-six interlocutors: six parteras (home birth attendants), nine pregnant women, four mothers, four healthcare providers, and three local government leaders. Participant observation occurred in the health clinic, participants' homes, and other spaces in a community with a population of 1,188 people. Drawing from narrative analysis, the findings suggest that women face structural obstacles to accessing high-quality childbirth care, which lead them to give birth at home instead of the hospital. These obstacles include financial barriers in obtaining facility-based care and poor quality of care, such as mistreatment in the facility. The study highlights the importance of centreing community narratives in healthcare programming in order to bridge the implementation gap between women in rural communities, healthcare workers, and policymakers.

DECOMPOSING THE SOCIOECONOMIC INEQUALITY IN UTILIZATION OF MATERNAL HEALTH CARE SERVICES IN SELECTED COUNTRIES OF SOUTH ASIA AND SUB-SAHARAN AFRICA

The gap in access to maternal health care services is a challenge of an unequal world. In 2015, each day about 830 women died due to complications of pregnancy and childbirth. Almost all of these deaths occurred in low-resource settings, and most could have been prevented. This study quantified the contributions of the socioeconomic determinants of inequality to the utilization of maternal health care services in four countries in diverse geographical and cultural settings: Bangladesh, Ethiopia, Nepal and Zimbabwe. Data from the 2010-11 Demographic and Health Surveys of the four countries were used, and methods developed by Wagstaff and colleagues for decomposing socioeconomic inequalities in health were applied. The results showed that although the Concentration Index (CI) was negative for the selected indicators, meaning maternal health care was poorer among lower socioeconomic status groups, the level of CI varied across the different countries for the same outcome indicator: CI of -0.1147, -0.1146, -0.2859 and -0.0638 for &lt;3 antenatal care visits; CI of -0.1338, -0.0925, -0.1960 and -0.2531 for non-institutional delivery; and CI of -0.1153, -0.0370, -0.1817 and -0.0577 for no postnatal care within 2 days of delivery for Bangladesh, Ethiopia, Nepal and Zimbabwe, respectively. The marginal effects suggested that the strength of the association between the outcome and explanatory factors varied across the different countries. Decomposition estimates revealed that the key contributing factors for socioeconomic inequalities in maternal health care varied across the selected countries. The findings are significant for a global understanding of the various determinants of maternal health care use in high-maternal-mortality settings in different geographical and socio-cultural contexts.

A mixed methods systematic review of success factors of mhealth and telehealth for maternal health in Sub-Saharan Africa

Access to health care is still limited for many women in sub-Saharan Africa (SSA), while it remains an important determinant of maternal mortality and morbidity. Information and communication technologies (ICTs), such as mhealth and telehealth, can help to facilitate this access by acting on the various obstacles encountered by women, be they socio-cultural, economic, geographical or organizational. However, various factors contribute to the success of mhealth and telehealth implementation and use, and must be considered for these technologies to go beyond the pilot project stage. The objective of this systematic literature review is to synthesize the empirical knowledge on the success factors of the implementation and use of telehealth and mhealth to facilitate access to maternal care in SSA. The methodology used is based on that of the Cochrane Collaboration, including a documentary search using standardized language in six databases, selection of studies corresponding to the inclusion criteria, data extraction, evaluation of study quality, and synthesis of the results. A total of 93 articles were identified, which allowed the inclusion of seven studies, six of which were on mhealth. Based on the framework proposed by Broens et al., we synthesized success factors into five categories: (I) technology, such as technical support to maintain, troubleshoot and train users, good network coverage, existence of a source of energy and user friendliness; (II) user acceptance, which is facilitated by factors such as unrestricted use of the device, perceived usefulness to the worker, adequate literacy, or previous experience of use ; (III) short- and long-term funding; (IV) organizational factors, such as the existence of a well-organized health system and effective coordination of interventions; and (V) political or legislative aspects, in this case strong government support to deploy technology on a large scale. Telehealth and mhealth are promising solutions to reduce maternal morbidity and mortality in SSA, but knowledge on how these interventions can succeed and move to scale is limited. Success factors identified in this review can provide guidance on elements that should be considered in the design and implementation of telehealth and mhealth for maternal health in SSA.

Comparing Maternal Services Utilization and Expense Reimbursement before and after the Adjustment of the New Rural Cooperative Medical Scheme Policy in Rural China

Background

The New Rural Cooperative Medical Scheme (NCMS) includes a maternal care benefits package that is associated with increasing maternal health services. The local compensation policies have been frequently adjusted in recent years. This study examined the association between the NCMS maternal-services policy adjustment and expense reimbursement in Yuyao, China.

Methods

Two household surveys were conducted in Yuyao in 2008 and 2011 (before and after the NCMS policy adjustment, respectively). Local women (N = 154) who had delivery history in the past three years were recruited. A questionnaire was used to collect information about delivery history, maternal health services utilization (prenatal care, postnatal care, and the grade of delivery institutions), NCMS participation, and reimbursement status. Logistic regression analyses were used to predict the association between policy adjustment and maternal health utilization and the association between policy adjustment and out-of-pocket proportion. Next, t-tests and covariance analyses adjusting for household income were used to compare the out-of-pocket proportion between 2008 and 2011.

Results

Results revealed that compensation policy adjustment was associated with an increase in postnatal visits (adjusted OR = 3.32, p = 0.009) and the use of second level or above institutions for delivery (adjusted OR = 2.32, p = 0.03) among participants. In 2008, only 9.1% of pregnant women received reimbursement from the NCMS; however, this rate increased to 36.8% in 2011. After policy adjustment, there were no significant changes in the proportion of out-of-pocket expenses shared in delivery fee (F = 0.24, p = 0.63) and in household income (F = 0.46, p = 0.50).

Conclusions

Financial compensation increase improved maternal health services utilization; however, this effect was limited. Although the reimbursement rate was raised, the out-of-pocket proportion was not significant changed; therefore, the compensation design scheme must be adjusted in practice.

The availability of emergency obstetric care in the context of the JSY cash transfer programme in Madhya Pradesh, India

Background

Since 2005, India has implemented a national cash transfer programme, the Janani Suraksha Yojana (JSY), which provides women a cash transfer upon giving birth in an existing public facility. This has resulted in a steep rise in facility births across the country. The early years of the programme saw efforts being made to strengthen the ability of facilities to provide obstetric care. Given that the JSY has been able to draw millions of women into facilities to give birth (there have been more than 50 million beneficiaries thus far), it is important to study the ability of these facilities to provide emergency obstetric care (EmOC), as the functionality of these facilities is critical to improved maternal and neonatal outcomes. We studied the availability and level of provision of EmOC signal functions in public facilities implementing the JSY programme in three districts of Madhya Pradesh (MP) state, central India. These are measured against the World Health Report (WHR) 2005benchmarks. As a comparison, we also study the functionality and contribution of private sector facilities to the provision of EmOC in these districts.

Methods

A cross-sectional survey of all healthcare facilities offering intrapartum care was conducted between February 2012 and April 2013. The EmOC signal functions performed in each facility were recorded, as were human resource data and birth numbers for each facility.

Results

A total of 152 facilities were surveyed of which 118 were JSY programme facilities. Eighty-six percent of childbirths occurred at programme facilities, two thirds of which occurred at facilities that did not meet standards for the provision basic emergency obstetric care. Of the 29 facilities that could perform caesareans, none could perform all the basic EmOC functions. Programme facilities provided few EmOC signal functions apart from parenteral antibiotic or oxytocic administration. Complicated EmOC provision was found predominantly in non-programme (private) facilities; only one of six facilities able to provide such care was in the public sector and therefore in the JSY programme. Only 13 % of all qualified obstetricians practiced at programme facilities.

Conclusions

Given the high proportion of births in public facilities in the state, the JSY programme has an opportunity to contribute to the reduction in maternal and perinatal mortality However, for the programme to have a greater impact on outcomes; EmOC provision must be significantly improved.. While private, non-programme facilities have better human resources and perform caesareans, most women in the state give birth under the JSY programme in the public sector. A demand-side programme such as the JSY will only be effective alongside an adequate supply side (i.e., a facility able to provide EmOC).

Empowerment, intimate partner violence and skilled birth attendance among women in rural Uganda

BACKGROUND

There is limited research on how the empowerment of women and intimate partner violence (IPV) are associated with skilled birth attendance (SBA) among rural women in Uganda. Therefore, the aim of this paper was to investigate the association between women's empowerment, their experience of IPV and SBA in rural Uganda.

METHODS

Using data from the Uganda Demographic and Health Survey (UDHS), we selected 857 rural women who were in union, had given birth in the last 5 years preceding the survey and were selected for the domestic violence (DV) module. Frequency distributions were used to describe the background characteristics of the women and their partners. Pearson's chi-squared (χ (2)) tests were used to investigate the associations between SBA and women's empowerment; and partners' and women's socio-demographic factors including sexual violence. Multivariable logistic regression analyses were used to examine the association between SBA and explanatory variables.

RESULTS

More than half (55 %) of the women delivered under the supervision of skilled birth attendant. Women's empowerment with respect to participation in household decision-making, property (land and house) (co)ownership, IPV, and sexual empowerment did not positively predict SBA among rural women in Uganda. Key predictors of SBA were household wealth status, partners' education, ANC attendance and parity.

CONCLUSIONS

For enhancement of SBA in rural areas, there is a need to encourage a more comprehensive ANC attendance irrespective of number of children a woman has; and design interventions to enhance household wealth and promote men's education.

Addressing the Child and Maternal Mortality Crisis in Haiti through a Central Referral Hospital Providing Countrywide Care

The neonatal, infant, child, and maternal mortality rates in Haiti are the highest in the Western Hemisphere, with rates similar to those found in Afghanistan and several African countries. We identify several factors that have perpetuated this health care crisis and summarize the literature highlighting the most cost-effective, evidence-based interventions proved to decrease these mortality rates in low- and middle-income countries.To create a major change in Haiti's health care infrastructure, we are implementing two strategies that are unique for low-income countries: development of a countrywide network of geographic "community care grids" to facilitate implementation of frontline interventions, and the construction of a centrally located referral and teaching hospital to provide specialty care for communities throughout the country. This hospital strategy will leverage the proximity of Haiti to North America by mobilizing large numbers of North American medical volunteers to provide one-on-one mentoring for the Haitian medical staff. The first phase of this strategy will address the child and maternal health crisis.We have begun implementation of these evidence-based strategies that we believe will fast-track improvement in the child and maternal mortality rates throughout the country. We anticipate that, as we partner with private and public groups already working in Haiti, one day Haiti's health care system will be among the leaders in that region.

Bridging evidence, policy, and practice to strengthen health systems for improved maternal and newborn health in Pakistan

Policy and decision making should be based on evidence, but translating evidence into policy and practice is often sporadic and slow. It is recognised that the relationship between research and policy uptake is complex and that dissemination of research findings is necessary, but insufficient, for policy uptake. Political, social, and economic context, use of (credible) data and dialogues between and across networks of researchers and policymakers play important roles in evidence uptake. Advocacy is the process of mobilising political and public opinions to achieve specific aims and its role is crucial in mobilising key actors to push for policy uptake. Advocacy and research groups (i.e. those who would like to see research evidence used by policymakers) may use different approaches and tools to stimulate the diffusion of research findings. The use of mass- and social media, communication with study participants, and the involvement of stakeholders at the early stages of research development are examples of the approaches that can be employed to stimulate diffusion of evidence and increase evidence uptake. The Research and Advocacy Fund (RAF) for Maternal and Newborn Health (MNH) worked within the health system context in Pakistan with the aim of espousing the principles of evidence, advocacy, and dissemination to improve MNH outcomes. The articles included in this special issue are outputs of RAF and highlight where RAF’s approaches contributed to MNH policy reforms. The papers discuss critical health system issues facing Pakistan, including service delivery components, demand creation, equitable access, transportation interventions for improved referrals, availability of medicines and equipment, and health workforce needs. In addition to these tangible elements, the health system ‘software’, i.e. the power and the political and social contexts, is also represented in the collection. These articles highlight three considerations for the future: the growing importance of implementation research, the crucial need for participation and ownership, and the recognition that policymaking can be ‘informed’ by rather than ‘based-on’ evidence. The future challenge will be to continue the momentum RAF has created and to welcome a new era of health, wealth, and growth for Pakistan.

Impact of Birth Preparedness and Complication Readiness Interventions on Birth with a Skilled Attendant: A Systematic Review

BACKGROUND

Increased preparedness for birth and complications is an essential part of antenatal care and has the potential to increase birth with a skilled attendant. We conducted a systematic review of studies to assess the effect of birth preparedness and complication readiness interventions on increasing birth with a skilled attendant.

METHODS

PubMed, Embase, CINAHL and grey literature were searched for studies from 2000 to 2012 using a broad range of search terms. Studies were included with diverse designs and intervention strategies that contained an element of birth preparedness and complication readiness. Data extracted included population, setting, study design, outcomes, intervention description, type of intervention strategy and funding sources. Quality of the studies was assessed. The studies varied in BP/CR interventions, design, use of control groups, data collection methods, and outcome measures. We therefore deemed meta-analysis was not appropriate and conducted a narrative synthesis of the findings.

RESULTS

Thirty-three references encompassing 20 different intervention programmes were included, of which one programmatic element was birth preparedness and complication readiness. Implementation strategies were diverse and included facility-, community-, or home-based services. Thirteen studies resulted in an increase in birth with a skilled attendant or facility birth. The majority of authors reported an increase in knowledge on birth preparedness and complication readiness.

CONCLUSIONS

Birth Preparedness and Complication Readiness interventions can increase knowledge of preparations for birth and complications; however this does not always correspond to an increase in the use of a skilled attendant at birth.

Using the unmet obstetric needs indicator to map inequities in life-saving obstetric interventions at the local health care system in Kenya

BACKGROUND

Developing countries with high maternal mortality need to invest in indicators that not only provide information about how many women are dying, but also where, and what can be done to prevent these deaths. The unmet Obstetric Needs (UONs) concept provides this information. This concept was applied at district level in Kenya to assess how many women had UONs and where the women with unmet needs were located.

METHODS

A facility based retrospective study was conducted in 2010 in Malindi District, Kenya. Data on pregnant women who underwent a major obstetric intervention (MOI) or died in facilities that provide comprehensive Emergency Obstetric Care (EmOC) services in 2008 and 2009 were collected. The difference between the number of women who experienced life threatening obstetric complications and those who received care was quantified. The main outcome measures in the study were the magnitude of UONs and their geographical distribution.

RESULTS

566 women in 2008 and 724 in 2009 underwent MOI. Of these, 185 (32.7%) in 2008 and 204 (28.1%) in 2009 were for Absolute Maternal Indications (AMI). The most common MOI was caesarean section (90%), commonly indicated by Cephalopelvic Disproportion (CPD)-narrow pelvis (27.6% in 2008; 26.1% in 2009). Based on a reference rate of 1.4%, the overall MOI for AMI rate was 1.25% in 2008 and 1.3% in 2009. In absolute terms, 22 (11%) women in 2008 and 12 (6%) in 2009, who required a life saving intervention failed to get it. Deficits in terms of unmet needs were identified in rural areas only while urban areas had rates higher than the reference rate (0.8% vs. 2.2% in 2008; 0.8% vs. 2.1% in 2009).

CONCLUSIONS

The findings, if used as a proxy to maternal mortality, suggest that rural women face higher risks of dying during pregnancy and childbirth. This indicates the need to improve priority setting towards ensuring equity in access to life saving interventions for pregnant women in underserved areas.

Maternal health development programs: comparing priorities of bilateral and private donors

Background

The face of international aid for health and development is changing. Private donors such as foundations and corporations are playing an increasingly important role, working in international development as direct operators or in partnerships with governments. This study compares maternal health programs of new development actors to traditional governmental donors. It aims to investigate what maternal health programs large governmental donors, foundations and corporate donors are conducting, and how and why they differ.

Methods

A total of 263 projects were identified and analyzed. We focus on nine categories of maternal health programs: family planning services, focus on specific diseases, focus on capacity building, use of information and communication technology (ICT), support of research initiatives, cooperation with local non-state or state partners and cooperation with non-local non-state or state partners. Data analysis was carried out using Generalized Linear Mixed-Effects Models (GLMER).

Results

Maternal health policies of public and private donors differ with regard to strategic approaches, as can be seen in their diverging positions regarding disease focus, family planning services, capacity building, and partner choice. Bilateral donors can be characterized as focusing on family planning services, specific diseases and capacity-building while disregarding research and ICT. Bilateral donors cooperate with local public authorities and with governments and NGOs from other developed countries. In contrast, corporations focus their donor activities on specific diseases, capacity-building and ICT while disregarding family planning services and research. Corporations cooperate with local and in particular with non-local non-state actors. Foundations can be characterized as focusing on family planning services and research, while disregarding specific diseases, capacity-building and ICT. Foundations cooperate less than other donors; but when they do, they cooperate in particular with non-state actors, local as well as non-local.

Conclusions

These findings should help developing coordination mechanisms that embrace the differences and similarities of the different types of donors. As donor groups specialize in different contexts, NGOs and governments working on development and health aid may target donors groups that have specialized in certain issues.

Maternity care services and culture: a systematic global mapping of interventions

Background

A vast body of global research shows that cultural factors affect the use of skilled maternity care services in diverse contexts. While interventions have sought to address this issue, the literature on these efforts has not been synthesised. This paper presents a systematic mapping of interventions that have been implemented to address cultural factors that affect women's use of skilled maternity care. It identifies and develops a map of the literature; describes the range of interventions, types of literature and study designs; and identifies knowledge gaps.

Methods and Findings

Searches conducted systematically in ten electronic databases and two websites for literature published between 01/01/1990 and 28/02/2013 were combined with expert-recommended references. Potentially eligible literature included journal articles and grey literature published in English, French or Spanish. Items were screened against inclusion and exclusion criteria, yielding 96 items in the final map. Data extracted from the full text documents are presented in tables and a narrative synthesis. The results show that a diverse range of interventions has been implemented in 35 countries to address cultural factors that affect the use of skilled maternity care. Items are classified as follows: (1) service delivery models; (2) service provider interventions; (3) health education interventions; (4) participatory approaches; and (5) mental health interventions.

Conclusions

The map provides a rich source of information on interventions attempted in diverse settings that might have relevance elsewhere. A range of literature was identified, from narrative descriptions of interventions to studies using randomised controlled trials to evaluate impact. Only 23 items describe studies that aim to measure intervention impact through the use of experimental or observational-analytic designs. Based on the findings, we identify avenues for further research in order to better document and measure the impact of interventions to address cultural factors that affect use of skilled maternity care.

Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality

This paper complements the other papers in the Lancet Series on midwifery by documenting the experience of low-income and middle-income countries that deployed midwives as one of the core constituents of their strategy to improve maternal and newborn health. It examines the constellation of various diverse health-system strengthening interventions deployed by Burkina Faso, Cambodia, Indonesia, and Morocco, among which the scaling up of the pre-service education of midwives was only one element. Efforts in health system strengthening in these countries have been characterised by: expansion of the network of health facilities with increased uptake of facility birthing, scaling up of the production of midwives, reduction of financial barriers, and late attention for improving the quality of care. Overmedicalisation and respectful woman-centred care have received little or no attention.

Maternal and child mortality indicators across 187 countries of the world: converging or diverging

This study reassessed the progress achieved since 1990 in maternal and child mortality indicators to test whether the progress is converging or diverging across countries worldwide. The convergence process is examined using standard parametric and non-parametric econometric models of convergence. The results of absolute convergence estimates reveal that progress in maternal and child mortality indicators is diverging for the entire period of 1990-2010 [maternal mortality ratio (MMR) - β = .00033, p < .574; neonatal mortality rate (NNMR) - β = .04367, p < .000; post-neonatal mortality rate (PNMR) - β = .02677, p < .000; under-five mortality rate (U5MR) - β = .00828, p < .000)]. In the recent period, such divergence is replaced with convergence for MMR but diverged for all the child mortality indicators. The results of Kernel density estimate reveal considerable reduction in divergence of MMR for the recent period; however, the Kernel density distribution plots show more than one 'peak' which indicates the emergence of convergence clubs based on their mortality levels. For child mortality indicators, the Kernel estimates suggest that divergence is in progress across the countries worldwide but tended to converge for countries with low mortality levels. A mere progress in global averages of maternal and child mortality indicators among a global cross-section of countries does not warranty convergence unless there is a considerable reduction in variance, skewness and range of change.

Increased plasma levels of CK-18 as potential cell death biomarker in patients with HELLP syndrome

HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome represents a life-threatening pregnancy disorder with high fetal and maternal mortality, but its underlying molecular mechanisms remain unknown. Although apoptosis has been implicated in HELLP syndrome, its pathogenic role remains largely unclear. In the present study, we investigated whether the detection of apoptosis by novel plasma biomarkers is of diagnostic value in HELLP patients. For this purpose, we analyzed two biomarkers that specifically detect apoptosis or overall cell death of epithelial cells, such as hepatocytes or placental trophoblasts, through the release of caspase-cleaved or total (caspase-cleaved and uncleaved) cytokeratin-18 (CK-18) in plasma of HELLP patients compared with pregnant as well as non-pregnant healthy women. In addition, caspase activation and cell death were determined in placental tissues of HELLP patients and individuals with normal pregnancy. In contrast to pregnant or non-pregnant healthy controls, we observed significantly increased levels of both caspase-cleaved and total CK-18 in plasma of HELLP patients. Following delivery, CK-18 levels rapidly decreased in HELLP patients. Caspase activation and cell death were also elevated in placental tissues from HELLP patients compared with healthy pregnant women. These data demonstrate not only that apoptosis is increased in HELLP syndrome, but also that caspase-cleaved or total CK-18 are promising plasma biomarkers to identify patients with HELLP syndrome. Thus, further studies are warranted to evaluate the utility of these biomarkers for monitoring disease activity in HELLP syndrome.

Birthing choices among the Sabiny of Uganda

The paper examines maternal health-seeking behaviour among the Sabiny people of Eastern Uganda in relation to health policy ideals. It is based on a study of maternal health conducted between 2011 and 2012. Data were collected using in-depth interviews with mothers, focus group discussions with mothers and fathers and key informant interviews. The paper addresses what factors influence choice of place of delivery among the Sabiny. Findings reveal that the majority of Sabiny women opt for homebirths, with around one quarter delivering at health facilities. Some women would prefer to deliver at a health facility but do not manage to do so. Sabiny cultural beliefs and practices are a key factor influencing choice of place of birth. Comprehension of and accommodation to Sabiny concerns in available maternal health services is limited, highlighting the need to develop cultural competence among health workers and methods of accommodating (health-promoting) local practices. This should be accompanied by improved patient care and a narrowing of the gap between health workers and Sabiny communities by promoting outreach and community-based health interventions. The paper highlights how the implementation of policy might be tailored to specific local contexts.

Maternal health-seeking behavior: the role of financing and organization of health services in Ghana

This paper examines how organization and financing of maternal health services influence health-seeking behavior in Bosomtwe district, Ghana. It contributes in furthering the discussions on maternal health-seeking behavior and health outcomes from a health system perspective in sub-Saharan Africa. From a health system standpoint, the paper first presents the resources, organization and financing of maternal health service in Ghana, and later uses case study examples to explain how Ghana's health system has shaped maternal health-seeking behavior of women in the district. The paper employs a qualitative case study technique to build a complex and holistic picture, and report detailed views of the women in their natural setting. A purposeful sampling technique is applied to select 16 women in the district for this study. Through face-to-face interviews and group discussions with the selected women, comprehensive and in-depth information on health- seeking behavior and health outcomes are elicited for the analysis. The study highlights that characteristics embedded in decentralization and provision of free maternal health care influence health-seeking behavior. Particularly, the use of antenatal care has increased after the delivery exemption policy in Ghana. Interestingly, the study also reveals certain social structures, which influence women's attitude towards their decisions and choices of health facilities.

Preconception care in low- and middle-income countries: new opportunities and a new metric

Joel Ray and colleagues discuss the challenges and opportunities for improving pre-conception care for women in developing countries. Please see later in the article for the Editors' Summary

The expressions of CD200 and CD200R molecules on myeloid and lymphoid dendritic cells in pre-eclampsia and normal pregnancy

PROBLEM

The purpose of our study was to test the hypothesis that the expressions of CD200 and CD200R tolerance molecules are increased on peripheral blood dendritic cells (DCs) in normal pregnancy and decreased on peripheral blood DCs in pre-eclampsia.

METHOD OF STUDY

Thirty-three patients with pre-eclampsia, 38 normal pregnant women, and 10 healthy non-pregnant women were included in the study. Dendritic cells were isolated from peripheral blood, stained with monoclonal antibodies against blood dendritic cell antigens as well as CD200 and CD200R antigens, and estimated using flow cytometry.

RESULTS

The expressions of CD200 and CD200R molecules on CD1c(+) myeloid and BDCA-2(+) lymphoid DCs in the first trimester of normal pregnancy were significantly higher when compared to the luteal phase of the ovarian cycle. The expressions of CD200 molecule on CD1c(+) myeloid DCs were significantly lower in the third trimester of normal pregnancy when compared to the second trimester. The expressions of CD200R molecule on CD1c(+) myeloid DCs and BDCA-2(+) lymphoid DCs did not differ in pre-eclampsia and healthy third trimester pregnant women. However, the expressions of CD200 molecule on CD1c(+) myeloid and BDCA-2(+) lymphoid DCs were significantly higher in pre-eclampsia when compared to the healthy third trimester pregnant women.

CONCLUSION

The results suggest increased tolerogenic properties of myeloid and lymphoid DCs in normal human pregnancy. Moreover, they suggest a decrease in tolerogenic properties of DCs before delivery. It seems possible that higher expressions of CD200 molecule on CD1c(+) myeloid and BDCA-2(+) lymphoid DCs in pre-eclampsia may constitute the tolerogenic mechanism secondary to the pro-inflammatory response that is observed in this syndrome.

An ecological quantification of the relationships between water, sanitation and infant, child, and maternal mortality

BACKGROUND

Water and sanitation access are known to be related to newborn, child, and maternal health. Our study attempts to quantify these relationships globally using country-level data: How much does improving access to water and sanitation influence infant, child, and maternal mortality?

METHODS

Data for 193 countries were abstracted from global databases (World Bank, WHO, and UNICEF). Linear regression was used for the outcomes of under-five mortality rate and infant mortality rate (IMR). These results are presented as events per 1000 live births. Ordinal logistic regression was used to compute odds ratios for the outcome of maternal mortality ratio (MMR).

RESULTS

Under-five mortality rate decreased by 1.17 (95%CI 1.08-1.26) deaths per 1000, p < 0.001, for every quartile increase in population water access after adjustments for confounders. There was a similar relationship between quartile increase of sanitation access and under-five mortality rate, with a decrease of 1.66 (95%CI 1.11-1.32) deaths per 1000, p < 0.001. Improved water access was also related to IMR, with the IMR decreasing by 1.14 (95%CI 1.05-1.23) deaths per 1000, p < 0.001, with increasing quartile of access to improved water source. The significance of this relationship was retained with quartile improvement in sanitation access, where the decrease in IMR was 1.66 (95%CI 1.11-1.32) deaths per 1000, p < 0.001. The estimated odds ratio that increased quartile of water access was significantly associated with increased quartile of MMR was 0.58 (95%CI 0.39-0.86), p = 0.008. The corresponding odds ratio for sanitation was 0.52 (95%CI 0.32-0.85), p = 0.009, both suggesting that better water and sanitation were associated with decreased MMR.

CONCLUSIONS

Our analyses suggest that access to water and sanitation independently contribute to child and maternal mortality outcomes. If the world is to seriously address the Millennium Development Goals of reducing child and maternal mortality, then improved water and sanitation accesses are key strategies.

Apoptosis, proliferation and Fas ligand expression in placental trophoblast from pregnancies complicated by HELLP syndrome or pre-eclampsia

OBJECTIVE

To investigate apoptosis, proliferation and Fas ligand expression of placental trophoblast in the hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome and in pre-eclampsia (PE), and to compare this with normal pregnancies.

DESIGN

Prospective study.

SETTING

University hospital in Croatia.

SAMPLE

Placentae from women with HELLP syndrome (n=10), PE (n=10) and normal pregnancies (n=10).

METHODS

The HELLP syndrome was diagnosed with platelets <100×10(9) /L, aspartate aminotransferase (AST) and alanine transaminase (ALT) >70 U/L and lactic acid dehydrogenase (LDH) > 600 U/L. Pre-eclampsia was diagnosed at blood pressure >140/90 mmHg, with proteinuria >300 mg/L/24 hours. For detection of apoptosis and proliferation in villous trophoblast, antibodies M30 and Ki-67 were used. Expression of Fas ligand was assessed using immunohistochemistry and the semiquantitative HSCORE method.

MAIN OUTCOME MEASURES

Apoptosis, proliferation and Fas ligand expression in villous trophoblast.

RESULTS

Apoptosis, proliferation and Fas ligand expression were higher in villous trophoblast in HELLP syndrome than in the PE group (p=0.015, p=0.018 and p=0.002, respectively) and the control group (p=0.000, p=0.012 and p=0.049, respectively). Placentae from the PE group had higher levels of apoptosis (p=0.019), lower Fas ligand expression (p=0.029) and no difference in proliferation (p=0.887) compared with the control group.

CONCLUSIONS

There is an increase in apoptosis, proliferation and Fas ligand expression in placentae from women with HELLP syndrome compared with placentae from PE and normal pregnancies. Our findings indicate the possibility of differential mechanisms behind HELLP syndrome and PE.

A population-based surveillance study on severe acute maternal morbidity (near-miss) and adverse perinatal outcomes in Campinas, Brazil: the Vigimoma Project

BACKGROUND

Auditing of sentinel health events based on best-practice protocols has been recommended. This study describes a population-based investigation on adverse perinatal events including severe acute maternal morbidity (near-miss), maternal and perinatal mortality, as a health intervention to help improve the surveillance system.

METHODS

From October to December 2005, all cases of maternal death (MD), near-miss (NM), fetal deaths (FD), and early neonatal deaths (END), occurring in Campinas, Brazil, were audited by maternal mortality committees.

RESULTS

A total of 4,491 liveborn infants (LB) and 159 adverse perinatal events (35.4/1000 LB) were revised, consisting of 4 MD (89/100.000 LB) and 95 NM (21.1/1000 LB), 23.7 NM for each MD. In addition, 32 FD (7.1/1000 LB) and 28 END (6.2/1000 LB) occurred. The maternal death/near miss rate was 23.7:1. Some delay in care was recognized for 34%, and hypertensive complications comprised 57.8% of the NM events, followed by postpartum hemorrhage.

CONCLUSION

Auditing near miss cases expanded the understanding of the spectrum from maternal morbidity to mortality and the importance of promoting adhesion to clinical protocols among maternal mortality committee members. Hypertensive disorders and postpartum hemorrhage were identified as priority topics for health providers training, and organization of care.

Sustainability of community-capacity to promote safer motherhood in northwestern Tanzania: what remains?

OBJECTIVE

To examine the remains of the Community-Based Reproductive Health Project (CBRHP) implemented by CARE-Tanzania to address high maternal mortality in two rural districts.

METHODS

In early 2007, data were collected from 29 villages and used to assess sustainability of emergency transport systems, retention of village health workers (VHWs), and their potential impact on maternal health. Surveillance data from the Ministry of Health were reviewed to assess changes in prenatal and service use indicators.

RESULTS

From 2001 through 2006, the CBRHP-trained VHWs have continued to provide education and referrals to women in their communities including prenatal and emergency obstetric care; six villages with emergency transport systems have continued for more than 5 years providing free or low-cost transport to health facilities. Selected maternal and infant health indicators, such as early prenatal care, identification of pregnancy-related danger signs, and data on maternal and infant outcomes, improved in the two targeted districts over time.

CONCLUSIONS

The two components of CBRHP, work of VHWs and community-financing for emergency transport systems in six villages, have continued. Both of these promote maternal health and linkages with the health delivery systems. Surveillance data show changes in maternal health indicators that were targeted by the district-wide CBRHP interventions. Programs such as CBRHP, with focus on capacity-building and empowerment, can assist in mobilizing the formal and informal systems in communities, components of which may be sustained over time.

Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5

BACKGROUND

Maternal mortality remains a major challenge to health systems worldwide. Reliable information about the rates and trends in maternal mortality is essential for resource mobilisation, and for planning and assessment of progress towards Millennium Development Goal 5 (MDG 5), the target for which is a 75% reduction in the maternal mortality ratio (MMR) from 1990 to 2015. We assessed levels and trends in maternal mortality for 181 countries.

METHODS

We constructed a database of 2651 observations of maternal mortality for 181 countries for 1980-2008, from vital registration data, censuses, surveys, and verbal autopsy studies. We used robust analytical methods to generate estimates of maternal deaths and the MMR for each year between 1980 and 2008. We explored the sensitivity of our data to model specification and show the out-of-sample predictive validity of our methods.

FINDINGS

We estimated that there were 342,900 (uncertainty interval 302,100-394,300) maternal deaths worldwide in 2008, down from 526,300 (446,400-629,600) in 1980. The global MMR decreased from 422 (358-505) in 1980 to 320 (272-388) in 1990, and was 251 (221-289) per 100,000 livebirths in 2008. The yearly rate of decline of the global MMR since 1990 was 1.3% (1.0-1.5). During 1990-2008, rates of yearly decline in the MMR varied between countries, from 8.8% (8.7-14.1) in the Maldives to an increase of 5.5% (5.2-5.6) in Zimbabwe. More than 50% of all maternal deaths were in only six countries in 2008 (India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the Congo). In the absence of HIV, there would have been 281 500 (243,900-327,900) maternal deaths worldwide in 2008.

INTERPRETATION

Substantial, albeit varied, progress has been made towards MDG 5. Although only 23 countries are on track to achieve a 75% decrease in MMR by 2015, countries such as Egypt, China, Ecuador, and Bolivia have been achieving accelerated progress.

FUNDING

Bill & Melinda Gates Foundation.

Programme alignment in higher-level planning processes: a four-country case-study for Sexual and Reproductive Health

With international development assistance focussed on poverty reduction, national and sector-wide planning processes have become increasingly important in setting agendas. Sector-Wide Approaches (SWAps), Poverty Reduction Strategy Papers (PRSPs), and other higher level planning processes, including Millennium Development Goals (MDGs) reporting, have required new levels of engagement in national and sectoral planning processes. For Sexual and Reproductive Health (SRH), this has had mixed consequences, despite raising the profile of SRH in national planning agendas, and emphasizing the potential of SRH to contribute to the reduction of poverty.Drawing on case-study research from four countries, this paper analyzes alignment of SRH policy with higher-level planning processes. It found that SRH managers are rarely engaged in higher-level planning processes, and while SRH features prominently in the [health] sections of PRSPs, it is not reflected in other sections, and does not necessarily correspond to more resources. Despite these limitations, these planning processes offer synergies that could improve the contribution of SRH to health sector development and poverty reduction. The paper recommends that local donor organizations, including key UN agencies, offer greater support for SRH programme managers in promoting the pro-poor and systems-wide strengths of SRH programmes to planners and policy makers.

Human resources and the quality of emergency obstetric care in developing countries: a systematic review of the literature

BACKGROUND

This paper reports on a systematic literature review exploring the importance of human resources in the quality of emergency obstetric care and thus in the reduction of maternal deaths.

METHODS

A systematic search of two electronic databases (ISI Web of Science and MEDLINE) was conducted, based on the following key words "quality obstetric* care" OR "pregnancy complications OR emergency obstetric* care OR maternal mortality" AND "quality health care OR quality care" AND "developing countries. Relevant papers were analysed according to three customary components of emergency obstetric care: structure, process and results.

RESULTS

This review leads to three main conclusions: (1) staff shortages are a major obstacle to providing good quality EmOC; (2) women are often dissatisfied with the care they receive during childbirth; and (3) the technical quality of EmOC has not been adequately studied. The first two conclusions provide lessons to consider when formulating EmOC policies, while the third point is an area where more knowledge is needed.

Professionals with delivery skills: backbone of the health system and key to reaching the maternal health Millennium Development Goal

The attainment of the fifth Millennium Development Goal requires adequate national reserves of skilled birth attendants. Nurses, midwives, and their equivalents form the frontline of the formal health system are a critical element of global efforts to reduce ill-health and poverty in the poorest areas of the world. Planning and policies supporting these cadres of workers must be placed high on the development agenda and championed by key international and national players. This article first sets forth an argument for the equity and efficiency of nurses, midwives, and their equivalents as the cadre largely responsible for maternal health. Second, it traces the root causes of neglect of this critical cadre, including a vacuum in political will in the context of poverty, lack of protections for frontline workers, the historical political position of the field of midwifery, lack of a pipeline of secondary school graduates, and gender inequity. Investment in the largely female cadre that cares for the majority of the world's poorer women has simply not been a high enough priority. Five key policy recommendations include harnessing political will and adequate metrics, protection of frontline workers' safety and livelihoods, ensuring an adequate pipeline with a focus on girls' education, donor support for training and professional organizations, and a rapid scale-up of a robust cadre of delivery care professionals. Finally, a call for unified international support of rapid scale-up of cadres of delivery care workers is put forth.

Collapsing the vertical-horizontal divide: an ethnographic study of evidence-based policymaking in maternal health

Using the international maternal health field as a case study, we draw on ethnographic research to investigate how public health researchers and policy experts are responding to tensions between vertical and horizontal approaches to health improvement. Despite nominal support for an integrative health system approach, we found that competition for funds and international recognition pushes professionals toward vertical initiatives. We also highlight how research practices contribute to the dominance of vertical strategies and limit the success of evidence-based policymaking for strengthening health systems. Rather than support disease-and subfield-specific advocacy, the public health community urgently needs to engage in open dialogue regarding the international, academic, and donor-driven forces that drive professionals toward an exclusive interest in vertical programs.

Safe motherhood in Ghana: Still on the agenda?

OBJECTIVE

This paper is an exploration of health sector and programming issues that resulted from a description of safe motherhood activities in Ghana.

METHODS

Descriptions of safe motherhood programmes were collected from various stakeholders through structured interviews. The characteristics of the programmes were compared to national safe motherhood aims and in the context of the reproductive health and sector-wide environment in Ghana.

RESULTS

Thirteen safe motherhood programmes were described. Their goals were wide ranging and did not necessarily target pregnant and postpartum women only. Community based interventions were slightly less dominant than service provision activities. A broad funding base was identified, strongly represented by external donors. Many funding contributions were not part of the Ghana government's Sector-Wide Approach (SWAp) to health.

CONCLUSIONS

Although reduction in maternal mortality ratio is a priority in Ghana's policy, many funding agencies supporting what are known as "safe motherhood" programmes are actually pursuing a somewhat broader reproductive health agenda. The evidence that this situation has actually led to a dilution of the maternal mortality reduction agenda is inconclusive, although our analysis has resulted in lessons which could be used to avert any risk to achieving this key millennium development goal. Government can use the SWAp to keep interests focused on the need for maternal mortality reduction, without detriment to other priorities. Strengthening partnerships will allow civil society and community focused interests to have a voice in influencing SWAp agendas. Good programme design with clear understanding of the link between programme components and objectives will help in making sure that maternal mortality targets are indeed achieved.

Ensuring financial access to emergency obstetric care: three years of experience with Obstetric Risk Insurance in Nouakchott, Mauritania

INTRODUCTION

The high cost of emergency obstetric care (EmOC) is a catastrophic health expenditure for households, causing delay in seeking and providing care in poor countries.

METHODS

In Nouakchott, the Ministry of Health instituted Obstetric Risk Insurance to allow obstetric risk sharing among all pregnant women on a voluntary basis. The fixed premium (US$21.60) entitles women to an obstetric package including EmOC and hospital care as well as post-natal care. The poorest are enrolled at no charge, addressing the problem of equity.

RESULTS

95% of pregnant women in the catchment area (48.3% of the city's deliveries) enrolled. Utilization rates increased over the 3-year period of implementation causing quality of care to decline. Basic and comprehensive EmOC are now provided 24/7. The program has generated US$382,320 in revenues, more than twice as much as current user fees. All recurrent costs other than salaries are covered.

CONCLUSION

This innovative sustainable financing scheme guarantees access to obstetric care to all women at an affordable cost.

Ethics in public health research: minding the gaps: a reassessment of the challenges to safe motherhood

Maternal and perinatal mortality reduction has remained a priority on the international health agenda for nearly 2 decades. During this time, strategies for achieving these goals have shifted in emphasis from prevention of pregnancies to provision of care. Robust evidence is limited, particularly regarding what works best in delivering care in specific health system settings and at the population level. We describe the limited evidence base using a framework that highlights the consequences of the major gaps in measurement, evidence, and action, and we discuss existing opportunities for bridging these gaps at the policy level. Capitalizing on current global policy interests and generating demand-driven evidence is a priority for enabling documentation of progress toward reaching the United Nations Millennium Development Goals for 2015.

Packaging health services when resources are limited: the example of a cervical cancer screening visit

BACKGROUND

Increasing evidence supporting the value of screening women for cervical cancer once in their lifetime, coupled with mounting interest in scaling up successful screening demonstration projects, present challenges to public health decision makers seeking to take full advantage of the single-visit opportunity to provide additional services. We present an analytic framework for packaging multiple interventions during a single point of contact, explicitly taking into account a budget and scarce human resources, constraints acknowledged as significant obstacles for provision of health services in poor countries.

METHODS AND FINDINGS

We developed a binary integer programming (IP) model capable of identifying an optimal package of health services to be provided during a single visit for a particular target population. Inputs to the IP model are derived using state-transition models, which compute lifetime costs and health benefits associated with each intervention. In a simplified example of a single lifetime cervical cancer screening visit, we identified packages of interventions among six diseases that maximized disability-adjusted life years (DALYs) averted subject to budget and human resource constraints in four resource-poor regions. Data were obtained from regional reports and surveys from the World Health Organization, international databases, the published literature, and expert opinion. With only a budget constraint, interventions for depression and iron deficiency anemia were packaged with cervical cancer screening, while the more costly breast cancer and cardiovascular disease interventions were not. Including personnel constraints resulted in shifting of interventions included in the package, not only across diseases but also between low- and high-intensity intervention options within diseases.

CONCLUSIONS

The results of our example suggest several key themes: Packaging other interventions during a one-time visit has the potential to increase health gains; the shortage of personnel represents a real-world constraint that can impact the optimal package of services; and the shortage of different types of personnel may influence the contents of the package of services. Our methods provide a general framework to enhance a decision maker's ability to simultaneously consider costs, benefits, and important nonmonetary constraints. We encourage analysts working on real-world problems to shift from considering costs and benefits of interventions for a single disease to exploring what synergies might be achievable by thinking across disease burdens.

Mobilising financial resources for maternal health

Coverage of cost-effective maternal health services remains poor due to insufficient supply and inadequate demand for these services among the poorest groups. Households pay too great a share of the costs of maternal health services, or do not seek care because they cannot afford the costs. Available evidence creates a strong case for removal of user fees and provision of universal coverage for pregnant women, particularly for delivery care. To be successful, governments must also replenish the income lost through the abolition of user fees. Where insurance schemes exist, maternal health care needs to be included in the benefits package, and careful design is needed to ensure uptake by the poorest people. Voucher schemes should be tested in low-income settings, and their costs and relative cost-effectiveness assessed. Further research is needed on methods to target financial assistance for transport and time costs. Current investment in maternal health is insufficient to meet the fifth Millennium Development Goal (MDG), and much greater resources are needed to scale up coverage of maternal health services and create demand. Existing global estimates are too crude to be of use for domestic planning, since resource requirements will vary; budgets need first to be developed at country-level. Donors need to increase financial contributions for maternal health in low-income countries to help fill the resource gap. Resource tracking at country and donor levels will help hold countries and donors to account for their commitments to achieving the maternal health MDG.

Preeclampsia: the Death of Goliath

In this review, a novel and unifying pathophysiologic mechanism of preeclampsia is presented whereby a minimal excess of placental immune complex production versus removal causes a proinflammatory autoamplification cascade of trophoblast apoptosis/necrosis and oxidative stress, culminating in clinical preeclampsia. This concept immediately leads to a plethora of new and robust therapeutic strategies.

A sector-wide approach to emergency obstetric care in Uganda

PURPOSE

To establish a baseline for the availability, utilization, and quality of EmOC, and to help develop an operational strategy based on the findings.

METHODS

A needs assessment of emergency obstetric care (EmOC) was carried out in 197 health facilities in 19 out of 56 districts in Uganda, covering 38% of the total population.

FINDINGS

There were a large number of missing signal functions at health facilities and an urgent need to improve the availability of EmOC.

CONCLUSION

By using the data from the assessment, it was possible to influence national policy through the health sector-wide approach (SWAp) and place EmOC high on the national agenda. A national strategy and roll out plan to strengthen EmOC is now in place.

Current strategies for the reduction of maternal mortality

The purpose of this article is to review current strategies for the reduction of maternal mortality and the evidence pertinent to these strategies. Historical, contextual and current literature were examined to identify the evidence base upon which recommendations on current strategies to reduce maternal mortality are made. Current safe motherhood strategies are designed based mostly on low grade evidence which is historical and observational, as well as on experience and a process of deductive reasoning. Safe motherhood strategies are complex public health approaches which are different from single clinical interventions. The approach to evidence used for clinical decision making needs to be reconsidered to fit with the practicalities of research on the effectiveness of strategies at the population level. It is unlikely that any single strategy will be optimal for different situations. Strengthening of the knowledge base on the effectiveness of public health strategies to reduce maternal mortality is urgently required but will need concerted action and international commitment.

Message in a bottle: sinking in a sea of safe motherhood concepts

The experiences of implementing maternal health programmes over the last two decades have resulted in the development of many approaches and concepts to address the problems of maternal death and disability in developing countries. These safe motherhood "messages" are generally conveyed from international organisations to implementers of programmes working in developing countries. The messages are sometimes unclear, ambiguous and open to misinterpretation. Case studies are used to describe varying interpretations of messages on essential and emergency obstetric care, skilled attendance at delivery and measurement of progress. Limited technological access to information, rapidly changing ideology, overly complicated terminology, inadequate evidence, poor international and inter-agency consensus are key reasons contributing to confusion in implementation. Policy-implementation gaps can be bridged with better needs-based evidence, improved consistency and means of delivery of global messages, building capacity, strengthening partnerships and more inclusive participation in the global arena.

Improving knowledge of antenatal care (ANC) among pregnant women: a field trial in central Java, Indonesia

The need for reducing maternal mortality has become a paramount concern in developing countries including Indonesia. One of the strategies for reducing maternal mortality in Indonesia is the provision of antenatal care (ANC). Previous studies have reported the advantages and disadvantages of ANC. The purpose of this study is to ascertain if a new approach to ANC can improve pregnant women's knowledge of its benefits. An experimental design with 60 pregnant women from 10 cluster villages is used in this study. The intervention group received the new approach to ANC, while the control group received routine ANC. The findings show that the improvement of knowledge in the intervention group is significant particularly in the knowledge about healthy pregnancy (p=0.012), pregnancy complications (p=0.01), safe birth (p=0.01) and taking care of the newborn (p=0.012). The improvement of knowledge was significantly influenced by the respondents' educational back ground (p=0.002) and socio-economic status (p=0.027). This study recommends that the new approach to ANC be considered to educate pregnant women regarding safe birth and it is considered as one of the strategies that may be adopted to reduce maternal mortality.

An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan

BACKGROUND

There are approximately 4 million neonatal deaths and half a million maternal deaths worldwide each year. There is limited evidence from clinical trials to guide the development of effective maternity services in developing countries.

METHODS

We performed a cluster-randomized, controlled trial involving seven subdistricts (talukas) of a rural district in Pakistan. In three talukas randomly assigned to the intervention group, traditional birth attendants were trained and issued disposable delivery kits; Lady Health Workers linked traditional birth attendants with established services and documented processes and outcomes; and obstetrical teams provided outreach clinics for antenatal care. Women in the four control talukas received usual care. The primary outcome measures were perinatal and maternal mortality.

RESULTS

Of the estimated number of eligible women in the seven talukas, 10,114 (84.3 percent) were recruited in the three intervention talukas, and 9443 (78.7 percent) in the four control talukas. In the intervention group, 9184 women (90.8 percent) received antenatal care by trained traditional birth attendants, 1634 women (16.2 percent) were seen antenatally at least once by the obstetrical teams, and 8172 safe-delivery kits were used. As compared with the control talukas, the intervention talukas had a cluster-adjusted odds ratio for perinatal death of 0.70 (95 percent confidence interval, 0.59 to 0.82) and for maternal mortality of 0.74 (95 percent confidence interval, 0.45 to 1.23).

CONCLUSIONS

Training traditional birth attendants and integrating them into an improved health care system were achievable and effective in reducing perinatal mortality. This model could result in large improvements in perinatal and maternal health in developing countries.

Impact of organizational change on the delivery of reproductive services: a review of the literature

In order to understand the impact of specific maternal health interventions, it is necessary to understand the likely effect of the health system structure. An important aspect of this structure is the organizational culture. Many systems in low-income countries have been based on a centrally planned and financed system. In recent years a series of organizational changes have been introduced into many systems and these substantially alter the way in which the system operates and impacts on reproductive health care provision. The main changes reviewed in this paper are: (i) decentralization, (ii) privatization and (iii) integration and sector wide approaches. Each of these changes is seen to have important implications for reproductive health. In each case it is clear that the nature of the impact depends crucially on the way it is implemented. Quantifying the impact of these changes remains extremely difficult given the many different ways they can be introduced and the many confounding factors that affect the overall impact. The literature does, however, point to a number of key issues that impinge on the way in which change is likely to affect reproductive health initiatives.

Human resources and health outcomes: cross-country econometric study

BACKGROUND

Only a few studies have investigated the link between human resources for health and health outcomes, and they arrive at different conclusions. We tested the strength and significance of density of human resources for health with improved methods and a new WHO dataset.

METHODS

We did cross-country multiple regression analyses with maternal mortality rate, infant mortality rate, and under-five mortality rate as dependent variables. Aggregate density of human resources for health was an independent variable in one set of regressions; doctor and nurse densities separately were used in another set. We controlled for the effects of income, female adult literacy, and absolute income poverty.

FINDINGS

Density of human resources for health is significant in accounting for maternal mortality rate, infant mortality rate, and under-five mortality rate (with elasticities ranging from -0.474 to -0.212, all p values < or = 0.0036). The elasticities of the three mortality rates with respect to doctor density ranged from -0.386 to -0.174 (all p values < or = 0.0029). Nurse density was not associated except in the maternal mortality rate regression without income poverty (p=0.0443).

INTERPRETATION

In addition to other determinants, the density of human resources for health is important in accounting for the variation in rates of maternal mortality, infant mortality, and under-five mortality across countries. The effect of this density in reducing maternal mortality is greater than in reducing child mortality, possibly because qualified medical personnel can better address the illnesses that put mothers at risk. Investment in human resources for health must be considered as part of a strategy to achieve the Millennium Development Goals of improving maternal health and reducing child mortality.