Ending preventable maternal deaths: the time is now, 2013 World Health Organization

Publication date: 2013

Comment www.thelancet.com/lancetgh Vol 1 October 2013 e176 Ending preventable maternal deaths: the time is now Between 1990 and 2010, maternal mortality decreased globally by nearly 50%, from 543 000 maternal deaths per year to 287 000,1 with the greatest reductions in the second half of this period. A major catalyst for this progress was the target set by Millennium Development Goal 5: reduction of the maternal mortality ratio by 75% between 1990 and 2015. Later, a second target on reproductive health was added, which has undoubtedly contributed to accelerated progress. In tandem, countries and the international community enhanced their commitment to support, develop, and implement eff ective interventions to improve the health of women, especially during pregnancy and childbirth, and post-partum. As 2015 approaches, attention turns to what has been achieved—and what lies ahead for the global development goals, including those for maternal and child health.2 In 2012, encouraged by the substantial reduction in mortality for children younger than 5 years, the global community (spearheaded by the governments of Ethiopia, India, and the USA, in collaboration with UNICEF, WHO, and other partners) put forward a vision of ending preventable child deaths.3,4 As a benchmark of this vision, a target for post-2015 was proposed. The target that “all countries should achieve a national under-5 mortality rate (U5MR) of below 20 deaths per 1000 live births by 2035, and the global average U5MR should decline to 15 deaths per 1000 in 2035” was ambitious but achievable, according to analyses and modelling of the potential eff ect of interventions to reduce child mortality.4,5 As countries and international platforms engage in post-2015 planning, now is the time to envision the ending of preventable maternal deaths, as stressed in a recent manifesto for maternal health.2 The global health community should build on past successes, and accelerate progress towards elimination of all preventable maternal mortality within a specifi ed period. WHO, the US Government, and many others have started processes to defi ne a new vision for maternal health, including discussion of potential targets. The initial technical discussions convened by WHO as part of this process, with country-level programme managers, scientists, professional organisations, donors, and other partner agencies, resulted in proposals to take forward a bold vision of ending preventable maternal deaths, around which the international community can rally. The analyses done as a background to the discussions show the feasibility of this vision. An ambitious but realistic global target is to reduce maternal mortality ratios to less than 50 per 100 000 livebirths by 2035. Dependent on which target year is selected, this would translate to a maternal mortality ratio of less than 90 by 2025, or 70 by 2030 (fi gure). In view of the accumulated experience of the global health community, with many countries achieving rapid reductions in maternal mortality in recent years, we believe that this target can be reached worldwide. Additionally, we propose a new method to measure and track progress in every country, based on achievement of defi ned milestone values according to initial maternal mortality ratios. This method would help to focus planning for maternal survival. For all countries with estimated maternal mortality ratios of less than 400 in 2010, the goal would be a steady progression past a series of 5 year milestones to reach the global target. The expectation that every country would cross one milestone within every 5 year interval will provide a method to measure each country’s progress, and will also contribute to global progress. The 5 year milestones for countries with high initial maternal mortality ratios (>400) would be individually designed and tracked. Countries with an estimated maternal mortality ratio of less than 100 would be expected to move to lower values according to defi ned milestones, but with a focus Figure: Estimated and target global MMR, 1990–2035 The target is 50 maternal deaths per 100 000 livebirths by 2035. MMR=maternal mortality ratios. OECD=Organisation for Economic Co-operation and Development. Global MMR 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 Target Estimated Highest MMR among OECD countries 0 100 200 300 400 M M R pe r 1 00 0 00 li ve bi rt hs Year Published Online August 19, 2013 http://dx.doi.org/10.1016/ S2214-109X(13)70059-7 © 2013 World Health Organization; licensee Elsevier. This is an Open Access article published without any waiver of WHO’s privileges and immunities under international law, convention, or agreement. This article should not be reproduced for use in association with the promotion of commercial products, services or any legal entity. There should be no suggestion that WHO endorses any specifi c organisation or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article’s original URL. Comment e177 www.thelancet.com/lancetgh Vol 1 October 2013 on internal subpopulations whose maternal mortality is higher than the national rate. New strategies to help to achieve rapid reductions in maternal mortality are needed. They need to be innovative and dynamic, with the aim to reach equity between and within countries. Targeted interventions should be implemented at scale, to address causes and conditions contributing to maternal deaths that vary across countries. Collection of data about the causes and conditions of every maternal death—eg, through maternal death surveillance and response—is a necessary fi rst step. Improved information enables development of strategies to respond to needs, and to address both clinical and distal causes of deaths, and will allow for targeted monitoring, accountability, and action. Strategies can be adapted to specifi c local causes, whether they are directly related to maternal mortality (eg, haemorrhage, pre-eclampsia or eclampsia, sepsis, or unsafe abortion) or indirectly related (eg, HIV, malaria, tuberculosis, anaemia, or non-communicable diseases). Strategies to implement targeted interventions to reduce maternal mortality need to address more than the clinical causes of death—they should respond to changing demographics, meet the specifi c needs of women for reproductive health, and address contextual features such as challenges caused by changes in health-care systems. These challenges include fi nancial incentives, the eff ects of decentralisation, the role of the private sector, and urbanisation. Universal access to high-quality health services, including family planning and information and services for reproductive health (especially for vulnerable and at-risk populations), should be put at the centre of eff orts to achieve the vision of ending maternal deaths. To accelerate and sustain the gains already achieved, international and national commitments are needed, such as those made in response to the UN Secretary General’s Every Woman Every Child report. Additionally, national-level processes to sharpen strategies for improvement of health and development beyond 2015 have already started in many countries. Ending of preventable maternal death is not a dream. Mahmoud Fathalla, past president of the International Federation of Obstetricians and Gynaecologists and former Chair of the WHO Advisory Committee on Health Research, said: “Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving.”6 Momentum to value women’s lives is growing—let us strengthen it. Flavia Bustreo, Lale Say, Marge Koblinsky, Thomas W Pullum, *Marleen Temmerman, Ariel Pablos-Méndez WHO, 1211 Geneva, Switzerland (FB, LS, MT); United States Agency for International Development, Washington, DC, USA (MK, AP-M); and ICF International, Fairfax, VA, USA (TWP) temmermanm@who.int We declare that we have no confl icts of interest. The views expressed here are those of the authors themselves and they do not necessarily represent the views of WHO or other organisations. 1 WHO, UNICEF, UNFPA, the World Bank. Trends in maternal mortality 1990 to 2010. Geneva: World Health Organization, 2012. 2 Langer A, Horton R, Chalamilla G. A manifesto for maternal health post-2015. Lancet 2013; 381: 601–02. 3 UNICEF. State of the world’s children. New York, NY: United Nations International Children’s Emergency Fund, 2012. 4 Glass RI, Guttmacher AE, Black RE. Ending preventable child death in a generation. JAMA 2012; 308: 141–42. 5 Winfrey W, McKinnon R, Stover J. Methods used in the Lives Saved Tool (LIST). BMC Public Health 2011, 11 (suppl 3): S32. 6 Fathalla MF. Human rights aspects of safe motherhood. Clin Obstet Gynecol 2006; 20: 409–19. For the Every Woman Every Child initiative see http://www. everywomaneverychild.org/ Ending preventable maternal deaths: the time is now References

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