In September 2000, the largest-ever gathering of world leaders took place in New York to usher in the new millennium. Here the United Nations (UN) Millennium Declaration was adopted and endorsed by 189 countries. Among the goals of the declaration was an aim to reduce maternal mortality rates by three-quarters between 1990 and 2015.
After almost nearly nine years, according to the most recent statistics from the World Health Organization (WHO), the goals set in 2000 still appear a long way from being achieved. In fact, of all the goals set in 2000, improving maternal health has been the least successful. Back then, the WHO estimated that around 500,000 women died during pregnancy and childbirth every year, mostly in the developing world. By 2009, that figure has barely changed.
It could be argued that a great deal of progress has already been made. In the 1800s, as many as 40% of all women died from maternal causes—in childbirth, or from related causes. By the 1900s the rate had improved, with one woman in every 100 dying from maternal causes.
Although there have been improvements in developed countries, statistics for the developing world remain dismally disappointing. Africa fares worst, with an estimated maternal mortality ratio of 900 in 100,000 live births, followed by South-East Asia where the figure is 450 in every 100,000. In Europe, just 27 women in 100,000 die from childbirth-related complications. Worryingly, of all the global health indicators, maternity mortality ratios show the greatest gap between rich and poor countries—over 90% of maternal deaths occur in developing countries.
Matching policy with funding
In Europe, a number of policy documents have been released in the past few years, which implies that the world means business. In 2005, the WHO released its Make Every Mother and Child Count report, and two years later the UK put its own policy report, Maternity Matters: choice, access and continuity of care in a safe service, on the table. However, in the UK's example, policy aims have not been matched by funding gains. Recent figures from the UK Department of Health, for example, show that although gross spending on general healthcare increased by 10.7% from 2007 to 2008, spending on maternity and reproductive health rose by just 2.7%.
Nevertheless, over the past few years the UK’s publicly funded National Health Service (NHS) has raised the bar for maternity services. After the release of the Maternity Matters policy, the Healthcare Commission (HCC) launched a review of 148 hospital trusts to assess a range of maternity care services, from early pregnancy through to post-natal services offered at home.
Interestingly, of the 26 trusts reviewed in London, 19 were among the worst in the UK in terms of maternity services. St George's Hospital in south London, which delivers 5,000 babies a year, was one of them. Teresa Manders, head of midwifery at St George's, admits that improving maternity care at the hospital is not without its challenges. However, she believes that the HCC review propelled hospitals towards real change and that The St George's Trust, among others in London, has taken the issue very seriously.
Even before the appointment of Ms Manders as part of a high-level dedicated task team to assess the state of its maternity services, an action plan was developed in the wake of the HCC review to address the trust’s shortcomings. This is now monitored on a quarterly basis by the NHS. Ms Manders' predecessor also held a general management role, but after the review it was recognised that a person with a specific professional focus on maternity services was essential for the post.
Setting a balance
A number of changes are being made at St George's as part of the broader national campaign to improve maternity services. One of the key issues across the UK is a lack of continuity of care, which can lead to conflicting diagnoses. To address this, St George's has recruited to its maximum in a bid to limit dependency on agency staff. A central objective has been to increase the ratio of midwives to women from early pregnancy through to post-natal care. But that is not always easy to achieve, according to Ms Manders. “There is a tension between what women want and expect from health professionals, and what midwives, many of whom also now want to work flexibility, can deliver,” she says. The desire to work flexibly is what many midwives want, but the problem, says Ms Manders, is that “women don’t labour like that”.
There are other challenges, too. Among some of London’s diverse ethnic communities, “people tend to have more children and we also see medical problems, like rheumatic fever, which we have seen very little of in the UK in the past,” she says. Other issues, which cross over to the broader public health agenda, are obesity (rates are as high as 20% in some parts of London), mental health problems, and HIV infection in pregnant women. The St George's Trust is setting up specific teams to work with pregnant women who are affected by these issues.
Whereas the first priority for public health officials in the developing world is to reduce maternal mortality rates, developed countries such as the UK have a different set of problems. Undoubtedly, though, developing countries definitely have a bigger hill to climb. As Adrian Gore, chief executive of Discovery Holdings, whose Discovery Health administers South Africa’s biggest private medical scheme, points out, the UK spends around US$3,500 a head on healthcare. “What people don’t realise is that it is almost half of our entire economy.”
Key ingredient
Irrespective of the different sets of challenges in each country, it appears that political will is a vital ingredient in reducing maternal mortality—one which, by and large, has been applied in the UK. Writing in the UK’s Maternity Matters policy document of 2007, Patricia Hewitt, the then secretary of state for health, said: “Good maternal health and high-quality maternity care throughout pregnancy and after birth can have a marked effect on the health and life chances of newborn babies, on the healthy development of children and on their resilience to problems encountered later in life.”
The WHO statistics show that in the developing world a motherless child is more likely to die before the age of two than an infant whose mother survives. Improvements in the health of pregnant women and new mothers can ensure that children survive their first years.
Was the millennium goal an impossible one to achieve? Not if the UK Department for International Development’s most recent maternal health strategy progress report is to be believed. Published in 2007, it says that just 2% of the world’s total development aid would be enough to reduce the numbers of women who die in childbirth by 75% by 2015.
As the 2015 deadline approaches, countries like Malaysia have proved that change is possible. According to Unicef, the UN children’s fund, maternal deaths in Malaysia nearly halved between 1957 and 1970, from around 280 to 141 per 100,000 live births. In 2005, the figure was 62 per 100,000 live births.
An article written by the Economist Intelligence Unit, specially commissioned by Philips