The international community resolved in 1987 to reduce maternal mortality around the
world. This resolution was strengthened in 2001 when 189 countries signed the Millennium
Declaration, committing themselves to Millennium Development Goal (MDG) 5 towards
improvement of maternal health. To accelerate national progress towards achievement
of MDG 5, a deeper understanding of what works at scale is needed. This demands a
common framework for measuring progress within and across countries and learning processes
that engage national stakeholders in using local evidence for programmatic decision-making,
identifying critical bottlenecks in scaling up, and generating context-specific implementation
solutions (1,2). However, progress has been slow and uneven. Now, as two decades ago,
more than 500,000 women die each year from pregnancy-related complications—nearly
half in South Asia.
“Getting on with what works”—the Lancet subtitle of an article on strategies for reduction
of maternal mortality—states that we know what works to reduce the number of maternal
deaths (3). The recommended priority strategy is quality intrapartum care where women
deliver in health facilities staffed with a team of midwives available 24 hours a
day, with a medical team at a referral hospital for back-up support in the case of
life-threatening complications. This strategy has the potential to impact not only
to reduce the number of maternal deaths but also mortality of newborns (4). Achieving
equitable access may require innovative financing mechanisms to increase participation
of care providers and women's access (5).
With leadership of the World Health Organization (WHO), the importance of such intrapartum
care is now acknowledged worldwide. Countries have responded positively but implementation
has varied. Many countries focus only on a part of the intrapartum care strategy:
in Bangladesh, intrapartum care presently focuses on the midwifery component; in India,
it is the facility component. Country and subcountry-level efforts are hampered due
to lack of data to guide implementation, with even less data available to tailor strategy
selection to the local context and assure active coverage and good quality (2,6).
Through the case studies in this issue of the Journal, we have initiated a response
to the growing call for evidence to support improved local implementation, gathering
lessons from practice within and across more and less successful areas of South Asian
countries. The aim is to build a body of knowledge by looking at patterns of problems
and solutions to improve safe motherhood implementation at the national and subcountry
levels.
Seeking lessons for implementation of safe motherhood programmes
“Getting what works to happen” means using internationally-recognized effective strategies
as a starting point rather than an end-point (6). Programmes may use knowledge of
successful intervention projects and trials in their planning but rolling out depends
on the interaction of policies and plans with existing formal and informal structures,
procedures and practices of stakeholders, programme managers, and care providers (6).
This dynamic interplay between the ideal and the existing health system is particularly
important for maternal health services, which do not deliver interventions through
a separate vertical programme or at one level of the health system; they rather build
on all levels of the existing health system and require their interaction.
What works for safe motherhood depends not only on the service context but also on
the context of recipients—their physical, social and cultural characteristics. At
the individual level, maternal health encompasses many conditions—from well-being
to mortality. This continuum may be traversed rapidly and without warning; complications
may present as a complex (e.g. both haemorrhage and sepsis), be aggravated by underlying
conditions (e.g. malaria, anaemia), and ultimately they affect at least two lives,
not just one. At the family level, the response to pregnancy and birthing is mediated
through a lens of joy or fear that greets having a child, the recognition and meaning
given to a complication, and long-standing authority patterns that determine decisions
about care-seeking. Education, poverty, traditions, and the environment (e.g. urban
or rural; desert or watery; high or low density of population) are keys to understanding
the community-level contextual fabric that cushions a safe motherhood programme.
A significant proportion of the variability in maternal mortality levels across and
within countries may be explained by these complex interactions between care and context.
Operational elements that may facilitate reduction in the number of maternal deaths
have been noted in histories of successful maternal care programmes in now developed
countries, such as Sweden, the United States, the United Kingdom, and Wales, and in
the more recent successes in some Asian countries, such as rural China, Malaysia,
Sri Lanka, and Thailand (Box 1) (8-11). Major challenges are typically the lack of
available skilled care at birth and referral support, poor quality of care at birth,
and lack of use of such care due to costs, distance, and other traditional barriers
(5,12). Transitioning to use of skilled and referral care and the lowering of the
maternal mortality ratio (MMR) can take years: Halving the MMR in developed countries,
for example, typically took a decade during the mid-20th century (13).
Box 1.
Programmatic elements of successful safe motherhood programmes (9-11)
•
High availability of birthing facilities, skilled birth attendants, and relevant specialists
•
Reduction of universal barriers to use (transport, costs, and perceived quality of
care)
•
Committed and supportive government policy that establishes the foundations for effective
maternal health services (e.g. professionalization of midwifery; availability of tools—skills,
supplies, time, and support; accountability; standards of care; drugs; and equipment)
•
Coordination of care, linking the community, primary facilities, and hospital care,
specifically emergency obstetric care, in a referral network
•
Targeting of areas with disadvantaged populations with greater programme resources
•
Use of information on magnitude, vulnerability, and inequities to inform policies
and programmes (e.g. gathered from monitoring systems, verbal autopsies/audits, confidential
inquiries, and transmitted via meetings of stakeholders and media)
South Asian countries were selected for the study as they have common elements across
their health service infrastructure initiated during colonial days. And while South
Asian countries currently experience relatively high levels of maternal mortality
(MMR), there are also stunning pockets of success. Sites successful in reducing maternal
mortality or in increasing the use of skilled birth attendance or emergency obstetric
care—Tamil Nadu and Gujarat in India; Matlab and Khulna in Bangladesh—and those not
as successful—northeast Bangladesh (Sylhet) and Rajasthan in India—were studied during
2004-2007.
Specific topics pursued in the case studies included barriers to/facilitators for
programmatic elements—human resources, including community-based skilled birth attendants
and specialists, referral units, referral systems—and the pathway leading to the primary
maternal killer, bleeding (e.g. recognition of postpartum haemorrhage, pollution,
blood-banks). Both primary (key-informant interviews, surveys, audits of maternal
deaths, stakeholder meetings) and secondary data (documents of plans, policies; survey
and facility reports; management information reports; and other extant data) were
analyzed.
Stakeholders' dialogue
Research is not enough to change policies and programmes in South Asia. Learning across
both successful and less-successful sites was done together with stakeholders. Stakeholders—policy-makers
and programme managers from the ministries of health at the national, state and district
levels in Bangladesh, India, and Pakistan—were involved to identify areas for study,
explore challenges within their systems, and share lessons across borders to stimulate
thinking towards improvement of policy and programme. Solutions to implementation
problems are typically multi-faceted as the challenges are complex and depend on social
rather than technical intervention (e.g. programme managers may not feel that s/he
has the control or authority for change). The participatory process of engagement
of stakeholders fostered critical reflection and learning focused on solutions to
address challenges within and beyond national and subnational borders; it enabled
stakeholders to dialogue about solutions with their peers and between levels of authority
for policy and programme.
Across all the sites, there were 18 meetings of stakeholders—two included officials
from all the three countries. In Gujarat, for example, there were four meetings of
stakeholders—three at the district level with both elected members and district health
officers, and one brought together national and state-level officers from other states.
The outcome was mutual learning within the state, among the states, and also between
national and state-level officials.
In Bangladesh, there were four meetings of stakeholders with government officials
from national and study districts; representatives from the United Nations, non-governmental
organizations, and relevant professional organizations also participated. While the
major constraint discussed, human resources, continues to be a bottleneck, ideas for
improvements stimulated by the Tamil Nadu success are now undergoing study.
The debates, including the resulting patterns of issues and solutions that became
the grist of these stakeholders' meetings (Box 2), are further detailed in the summary
paper, and individual papers in this issue of the Journal (14). Such debates on issues
of human resources, financing, management gaps, and availability of blood are just
a beginning; much more experimenting and learning on these and other implementation
issues of safe motherhood are needed, along with stakeholders' dialogue to foster
change and achieve scale for safe motherhood programmes based on more localized learning.
Box 2.
Selected context-specific innovations highlighted by national leadership in regional
meetings of stakeholders
Human resources
•
Cheeranjivi Yojona Scheme, a public-private partnership in Gujarat
•
Incentives for deployment and retention of specialized staff in rural areas (Tamil
Nadu and Kerala)
•
Round-the-clock 24-hour × 7-day comprehensive EmONC centres and obstetric first-aid
in PHCs (3 nurses system) in rural Tamil Nadu
•
Task shifting—MBBS medical officers for comprehensive EmOC (Bangladesh)
Access, quality, and accountability
•
Maternal death audit systems in Tamil Nadu and Kerala
•
Equity of access through the voucher scheme (Janani Suraksha Yojana) and its adaptations
in various states in India; voucher scheme in Bangladesh
•
Centralized emergency calling services through the Emergency Medical Research Institute
in Gujarat; similar services in Tamil Nadu and Andhra Pradesh; and through the Edhi
Foundation in Pakistan
•
Blood-banks in Maharasthra and Gujarat
Political will and leadership for safe motherhood
•
Enabling environment for change: role of local champions and partnerships with professional
associations in Tamil Nadu, Kerala, and Gujarat
•
Training for Programme Managers: India Institute of Management
•
Partnerships between institutions and researchers with higher-level national stakeholders
[Indian Institute of Management; International Centre for Diarrhoeal Disease Research,
Bangladesh (ICDDR,B)
EmOC=Emergency obstetric care; EmONC=Emergency obstetric and newborn care; PHCs=Primary
Health Centres
We are grateful to the UK Department for International Development for funding this
effort and for stimulating us to think beyond the conventional borders of topic and
country. We are also grateful to the stakeholders who enriched the process of dialogue
and learning with their leadership, commitment, experience, and example and who steer
the course for much of what happens in country. To them we dedicate this work: Dr.
P. Padmanabhan, Director of Public Health and Preventive Medicine and Director of
Family Welfare of Tamil Nadu, India; Dr. Amarjit Singh, Principal Secretary, Family
Welfare and Commissioner Health of Gujarat, India; Dr. Ajesh Desai, Dr. Vikas Desai,
and Dr. S.R. Patel, Government of Gujarat; Dr. V. Rajasekharan Nair, Chairman, Academic
Committee, KFOG of Kerala, India; Dr. Saleh Mohammad Rafique, Director, Primary Health
Care and Line Director, ESD, Directorate General of Health Services, Dhaka, Bangladesh;
Prof. Abdul Bayes Bhuiyan, Ex-President of Obstetrical and Gynaecological Society
of Bangladesh and, Focal Point, Community-based Skilled Birth Attendant Training Programme,
Dhaka, Bangladesh; Dr. Md. Nazrul Islam, Deputy Programme Manager, Reproductive Health
(EOC), Directorate General of Health Services, Dhaka, Bangladesh; Dr. Abdul Majid,
Special Secretary (Public Health), Health Department and Dr. Qazi Mujtaba Kamal, Provincial
Coordinator, National Programme for Family Planning and Primary Health Care (Lady
Health Worker Programme), Health Department, Government of Sindh, Pakistan; and Head
and staff of Reproductive Health Unit, ICDDR,B, Dhaka, Bangladesh and of Indian Institute
of Management, Ahmedabad, for the facilities and administrative support to the project.
ACKNOWLEDGEMENTS
The information and views presented in this article are solely those of the authors
and do not necessarily represent the views or the positions of the Department for
International Development (DFID), the U.K. Government, the U.S. Agency for International
Development or the U.S. Government.