The continuing high maternal mortality in developing countries is evidence that there is a need to identify and implement those strategies that are most effective at reducing maternal mortality. Reducing maternal mortality is complicated by a huge diversity of country contexts and the multifaceted nature of maternal health and its determinants. The Millennium Development Goal for maternal health (MDG-5) to reduce maternal mortality by two-thirds by 2015 will best be achieved by adopting a core strategy of health centre-based intrapartum care and safe motherhood programming. The effectiveness of public health strategies to reduce maternal mortality is urgently required but will need concerted action and international commitment.

Health centre intrapartum care

Intrapartum care based in health centres is appropriate for all as a longer-term strategy which dependent on strong health systems ensuring high coverage of midwifery services supported by timely and competent hospital care for reducing maternal mortality. Most maternal deaths occur during labour, delivery, or the first 24 h postpartum, and most complications cannot be predicted or prevented. Individual complications are quite rare and timely diagnosis and appropriate intervention requires considerable skill to prevent death and to avoid introducing harm. The best intrapartum-care strategy is likely to be one in which women routinely choose to deliver in a health centre, with midwives as the main providers, but with other attendants working with them in a team. The treatment component would include all basic emergency obstetric functions, apart from blood transfusions or surgery which would be available at the referral level as comprehensive emergency obstetric care. Ensuring basic essential obstetric care and basic emergency obstetric care were likely to be close enough if the need for emergency care arose in the antenatal or postpartum period. Intrapartum-care package can prevent a large proportion of obstetric deaths and the first level care save lives and manage emergencies which can bring maternal mortality.

Technologies encompass equipment, supplies (including medications), procedures and techniques have both good functionality (efficacy, effectiveness and safety) and good fit with the environment where they will be used are effective only if there are skilled and knowledgeable users. Progress will ultimately be dependent on strong health systems ensuring high coverage of midwifery services supported by timely and competent hospital care. These substantial achievements are thought to be due to a combination of factors including: long-term investment in midwifery training and referral hospitals; free care and a supportive system with regulation, control, and supervision of the medical and midwifery profession

Skilled attendants at delivery

A central focus of many safe motherhood efforts is the importance of skilled attendance at deliveries. Increasing the proportion of deliveries with skilled attendance is regarded as a crucial intervention strategy. Skilled attendance incorporates all that is needed to prevent maternal deaths. It has a preventive component of ‘watchful expectancy’ for normal deliveries as well as referral to professional care for emergencies. The normal delivery and preventive functions of basic care, including some emergency first aid, could be delivered by a skilled attendant in the home. Home-based intrapartum care is also inefficient in terms of the skilled attendant’s time and ability to cope with emergencies. Such care requires the skilled attendant to deal with first-aid for complications on their own or with help only from the family, rather than from other providers such as auxiliaries or doctors in health centres or hospitals, and to arrange transport for referral. Home-based care without assurance of links and transport to emergency obstetric care in facilities will also limit the effectiveness of this strategy and could compromise community confidence in the midwife.

Community health workers at home

Community health worker attending homes the day after birth to provide care for the newborn baby is now being promoted as an effective complementary strategy to one based on health professionals at delivery. Such a strategy assumes that community health workers are present at deliveries, which depends on families having informed them of the labour, and on their willingness to attend.

Relatives or traditional birth attendants at home

The default intrapartum-care strategy is lay (relatives or traditional birth attendant) home-based care, with little government provision of services. This approach is typical in the poorest countries and in the poorest rural populations within countries. The training of TBAs is another strategy upon which much emphasis has been placed. In many countries women prefer TBAs to midwives as their delivery attendant. TBAs are also likely to remain as delivery care attendants for some time because of difficulties experienced in posting trained professionals to rural areas in many developing countries. Traditional birth attendants identified early signs of complications during labour and delivery, and successfully referred women for treatment. TBA training appears to increase antenatal care attendance rates. Attendants can promote good perinatal hygiene and reduce mortality through promotion of home-based use of misoprostol after delivery to reduce haemorrhage and marketing of clean-birth kits on reducing death from sepsis.

Emergency obstetric care strategies (EmOC)

Emergency care is an essential requirement for reduction of a substantial proportion of maternal mortality and recommended health centre intrapartum-care strategy incorporates it. EmOC is a package of interventions focused on the direct obstetric complications that cause the majority of maternal deaths. Sufficient emergency obstetric care was available-both at the health centre (basic emergency obstetric care) and the referral hospital (comprehensive emergency obstetric care)-to treat the complications that cause most maternal deaths. Ensuring a ready supply of the emergency-obstetric-care package requires that health centres and hospitals are equipped to deal with the emergencies that reach them, and that timely care is given. Women with complications, particularly rapidly fatal intrapartum complications-can access such care, ideally within a couple of hours. This means overcoming delays in recognition of complications (the so-called first delay) and in gaining timely access to appropriate emergency obstetric care facilities. Trained traditional birth attendants can effect better referral, and skilled attendants in the home are assumed to recognise complications and act on them quickly. Other efforts have sought to improve transport, including through community mobilization. Capacity to provide adequate and timely emergency obstetric care is, however, the minimum standard a health system is ethically obliged to provide to begin to address maternal mortality. Most discussions of strategies to reduce maternal mortality concentrate on detection of problems early and provision of treatment to prevent them becoming life-threatening, or on treatment of life-threatening complications to prevent death.

Intrapartum-care strategies are acknowledged as the priority focus for reduction of maternal mortality, but the role of complementary strategies with different target groups, such as pregnant women or women not desiring pregnancy, are also important to consider. We recognise the potential for four such strategies-antenatal care, postpartum care, family planning, and safe abortion.

Antenatal care

The rationale for the widespread introduction of antenatal care (ANC) has been the belief that early signs of, or risk factors for, morbidity and mortality can be detected and that effective interventions are possible. Women seeking antenatal care may be more likely to seek professional care during delivery. ANC therefore still has importance as a potentially effective instrument to ensure better use of obstetric services. These strategies target a predominantly healthy population of pregnant women in order to screen and detect early signs of or risk factors for disease, followed by timely intervention,13 J Bale, B Stoll, A Mack and A Lucas, Improving birth outcomes: meeting the challenges in the developing world, National Academy of Sciences and Institute of Medicine, Washington, DC (2003). originally with the aspiration of reducing maternal and perinatal mortality and morbidity. Since antenatal care is one of the most widespread health services and coverage is often high, it increasingly serves as a means of distribution for other packages, for example, the roll-out of antimalarial drugs or of antiretroviral therapy for maternal HIV/AIDS.

Postpartum care

Most postpartum deaths occur the first day after birth and their management falls within the skilled attendance or emergency care strategies. During the postpartum period, physical, social, and mental problems can emerge, indicating a need for strategies that encompass both preventive and curative intervention packages. For life-threatening disorders during or after childbirth, strategies that encompass emergency obstetric care packages are the most effective and efficient approaches. The risk of death, however, decreases steadily by 2 days postpartum, and so the optimum means and timing of the distribution of routine postpartum care during the entire 6-week period is unclear, beyond recommendation that intrapartum-care strategies need to cover the very high-risk period up to 24 h postpartum. Postpartum home visits have been suggested

Family planning

Family planning was presented as one of the key strategies for maternal mortality reduction in developing countries. Family planning may prevent unwanted pregnancy (and illegal abortion), reduce the total numbers of births and have direct benefits from the contraceptive methods themselves. There is no doubt that widespread use of contraceptives will reduce the total numbers of maternal deaths hence lower the maternal mortality rate, as fewer women will be exposed to the risks of pregnancy. Maternal deaths could be eliminated if unplanned and unwanted pregnancies were prevented. To say that without pregnancy there would be no maternal death. Fertility reduction was undoubtedly an important factor in reducing maternal mortality and strategies to improve maternal health should resist political pressure to restrict access to contraception services and safe abortion

Safe abortion

Almost all deaths in early pregnancy were due to induced abortion, and a third of all maternal deaths were due to unsafe abortion. Good post-abortion care can make a contribution to reducing women die as a consequence of unsafe abortion. Essentially the strategy consists of the scaling up of good quality post-abortion care including the use of manual vacuum aspiration instead of dilatation and curettage leads to better patient care, shorter hospital stays, lower costs and increased contraceptive use and the adoption of local anaesthesia in lieu of general anaesthesia. Failing to prevent unwanted pregnancy leads some women to induce abortion. Mortality associated with medical termination of pregnancy in a safe environment is lower than that associated with delivery at term. Safe technologies for inducing abortion are available, including medical abortions (eg, with mifepristone or misoprostol), vacuum aspiration, and curettage. Care for post-abortion complications should be covered within emergency obstetric care packages, irrespective of the legal status of induced abortion.

Broader health and non-health strategies

Pre-existing ill-health is a risk factor for maternal mortality, particularly from indirect causes, and thus improvements in women’s general health status should help prevent some complications and deaths. Prevention or treatment of infections (eg, streptococcal infections that causes rheumatic heart disease, or HIV, syphilis, or malaria) or chronic disease (eg, diabetes and asthma) could help reduce indirect maternal deaths.

Micro-nutrient supplementation

Another preventive approach is being advocated for chronically malnourished populations in the form of micronutrient supplementation, which appears attractive as a potential intervention to reduce maternal and fetal mortality because it is believed to be cheap, safe and easier than the more fundamental changes in society that may be required. Widespread appeals for the promotion of micro-nutrient supplementation of pregnant or reproductive age women have been made, and some agencies have incorporated supplementation strategies in their policy agenda. Vitamin A and its precursors may affect maternal health through improvements of the immune and haematological status of the pregnant woman thus reduces maternal mortality in deficient areas. Supplementations of pregnant women with calcium as a means of prevent pregnancy-induced hypertension and pre-eclampsia in communities with low calcium intake. Iron supplementation in pregnancy improves maternal iron status and haemoglobin levels during pregnancy and immediately after delivery. These arguments are most widely made for nutritional status, where improvement of women’s haemoglobin, calcium, or iodine status, or of short stature is thought, for example, to reduce the risks of developing haemorrhage, eclampsia, or obstructed labour.

HIV/AIDS

The contribution to maternal deaths of diseases that are not unique to pregnancy is largely unknown in developing countries, partly owing to poor diagnostic capability and partly because pregnancies are often not reported for such causes. The inclusion or exclusion of causes that are not unique to the pregnancy (eg, HIV infection) can substantially affect the magnitude of maternal mortality. Many maternal deaths take place in regions where HIV is prevalent and has become a leading cause of pregnancy-related death in some hospitals where populations with a high prevalence of HIV. HIV infection in pregnancy increases the risk of obstetric complications;35 V Maiques-Montesinos, J Cervera-Sanchez, J Bellver-Pradas, A Abad-Carrascosa and V Serra-Serra, Post-cesarean section morbidity in HIV-positive women, Acta Obstet Gynecol Scand 78 (1999), pp. 789-792. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (42) HIV-related illness such as anaemia or tuberculosis might be aggravated by pregnancy; pregnancy might increase HIV-incidence; or HIV progression itself might be worsened by pregnancy.

Haemorrhage

Haemorrhage is the major cause of maternal death worldwide.11 KS Khan, D Wojdyla, L Say, AM Gulmezoglu and PF Van Look, WHO analysis of causes of maternal death: a systematic review, Lancet 367 (2006), pp. 1066-1074. Article | http://www.sciencedirect.com/scidirimg/icon_pdf.gifPDF (2366 K) | View Record in Scopus | Cited By in Scopus (299) Haemorrhage has long been known to be the one major cause of maternal mortality in which women were dying needlessly for want of common skills that every midwife and practitioner should possess. Whether or not a woman dies from bleeding during or after childbirth depends largely on access to timely and competent obstetric care. Median time from onset to death is about 6 h, so community-based treatments are needed in populations without easy access to facilities. Many deaths related to haemorrhage might be prevented or treated in the community if oral misoprostol was provided to government community health workers to provide rapid treatment at home. Use of misoprostol is a clinically effective, inexpensive, oral alternative that does not require refrigeration and has the potential to prevent many maternal deaths. Most women in shock secondary to infection or haemorrhage who do reach a health facility need prompt intensive care, and that these principles are as important to emphasise for all health workers as are midwifery skills for birth attendants.

Infection and sepsis

Infection and sepsis as a primary or underlying cause of maternal death is greatly under-reported and under-estimated in the poorest communities, and that awareness by families of the risks of infection and good access to antibiotics are keys. With a huge expansion in over-the-counter availability of antibiotics will help to decline in maternal mortality. Many informal health providers routinely recommend mothers take an antibiotic postpartum, and community treatment of maternal sepsis probably played a major part in the MMR decline. There are risks with over-the-counter antibiotics (resistance, unwanted side-effects, and incorrect diagnoses), so strategies are needed to improve appropriate government distribution, but a more liberal approach to antibiotic access in the poorest countries could save the lives of many mothers. Such a pronounced fall in maternal mortality is largely attributed to a decrease in the virulence of pathogens linked with puerperal sepsis, improved surgical techniques, and universal access to care.

Strategies like vital registration require functioning systems at both government and community level. A properly running health system is necessary for the implementation of strategies to reduce maternal mortality. The current major public health issues in low resource countries, safe motherhood is unique in requiring large numbers of clinical staff including some trained in surgical techniques. A human resource strategy with the objective of ensuring a supply of appropriately trained staff is thus essential. Many developing countries now face problems of retention of trained staff due to migration across countries and also from rural to urban areas. Secondly, in some countries with a small number of doctors and midwives it may be more appropriate to train all health professionals to competence level in obstetric care for complications.

Service quality improvement

In relation to maternal deaths the gathering of information on deaths with a view to finding out why the deaths occur, and what can be done to prevent them, is the keystone of quality assurance strategies. This can take the form of verbal autopsies in the community, facility-based maternal death reviews, confidential enquiries, reviewing cases of severe maternal morbidity (near-misses) and criterion-based clinical audit of life threatening complications. These methodologies are shown to have a better effect on health care practices and health care outcomes than other strategies.

a systematic review of studies of maternal mortality by WHO, severe bleeding, hypertensive diseases, and infections were the dominant causes.

community-based strategies in addition to health-centre-based intrapartum care, with recognition that infection, haemorrhage, and shock-related syndromes cause most maternal deaths in countries with high mortality rates. Compelling evidence supports four key policy recommendations. First, infection and sepsis as a primary or underlying cause of maternal death is greatly under-reported and under-estimated in the poorest communities, and that awareness by families of the risks of infection and good access to antibiotics are keys. Second, many deaths related to haemorrhage might be prevented or treated in the community if oral misoprostol was provided to government-based outreach health workers, rather than confined to facility-based management (although effectiveness trials are needed). Third, most women in shock secondary to infection or haemorrhage who do reach a health facility need prompt intensive care, and that these principles are as important to emphasise for all health workers as are midwifery skills for birth attendants. Fourth, a central focus of safer motherhood programmes, and a primary responsibility of government, is that women and communities are empowered to demand their rights to pregnancy, childbirth, and newborn care.

The persistent emphasis on global differences and strategies for maternal health has often entailed a neglect of biological, geographic, economic, and social differences in maternal mortality within populations. Targeting of interventions towards the most vulnerable groups (mostly rural populations and the poor) also means targeting improvements in measuring their burden of mortality, so enabling the monitoring of governments’ accountability for reducing this most basic of inequities-maternal death.