Midwives to the Rescue: Reducing Maternal Mortality

Jill Sheffield is the Founder and President of Family Care International (FCI).

I just returned from Malaysia, where I attended the International Federation of Obstetrics and Gynecology (FIGO) triennial congress. I traveled with some of my colleagues from Family Care International (FCI) to present results from the final evaluation of FCI's Skilled Care Initiative, a three-country project to increase the proportion of women who deliver with a "skilled attendant" – a trained and properly supported health care provider – in rural Africa. I'll be writing more about this initiative in my next posting.

In Kuala Lumpur, thousands of obstetricians and gynecologists gathered to share data from new studies, learn about new surgical techniques, and vote on their leadership. Among so many dedicated doctors who have made a lifelong commitment to promoting the latest and greatest in women's health, one could be lulled into thinking that women's health must be in good shape.

Sadly, over the past 20 years, maternal mortality rates have barely budged in much of the world. In some African countries, as many as one in 10 women will die of a pregnancy-related cause. Nicholas Kristoff's two columns in the New York Times (published in September) about the death of Prudence Lemokouno described the factors that contribute to maternal mortality. Ms. Lemokouno had a pregnancy complication which could have easily been dealt with had she received prompt obstetrical care, and when she and her family sought care, they encountered a range of barriers – financial, geographic, and cultural – that resulted in unacceptable delays, poor service, and ultimately, her death.

Any one of the wonderful doctors who met in Kuala Lumpur could have saved this woman's life, and they do save women's lives in their daily work. But they rarely work in the areas of highest need – among poor, rural communities – and the barriers between the life-saving care that these highly trained professionals can provide and the women who need them, can be high indeed. The "enabling environment" for health care providers – equipment, operating theaters, surgical supplies, efficient management and adequate salaries – simply does not exist in much of the world. A multi-sectoral approach is needed to reduce all the barriers to care that result in the deaths of over half a million women each year.

Malaysia provides us with a useful example of such an approach. After independence, Malaysia invested heavily in community-based midwives – well-trained health professionals, working as part of a team with doctors. These midwives now conduct most deliveries. Traditional birth attendants, who had previously attended women undergoing home births, were integrated into the health care system, tapping in to their special knowledge of the communities where they live. Significant national investment went to health care generally (for more on Malaysia's approach to reduce maternal deaths, see FCI's profile). The result is that now maternal deaths are extremely rare in Malaysia, where fully 97% of births are attended by a trained health care worker (my figures come from the latest Human Development Report, which was released this week). In contrast, in Cameroon where Ms. Lemokouno lived, just 62% of women receive such care. And Cameroon has one of the highest rates of skilled attendance at birth in Sub-Saharan Africa – Niger and Chad are at 16%, and in Ethiopia, a mere 6% of women receive medical care during child birth. In Malaysia, only 41 out of every 100,000 births results in the death of the mother; in Cameroon, this ratio is more than 10 times higher, with 730 women dying for every 100,000 births.

By the middle of next year, we will be halfway through the timeframe set by the Millennium Development Goals. Do we have any chance of meeting MDG 5 – reducing maternal mortality by three quarters by the year 2015? After returning from Malaysia, I am allowing myself to be optimistic.

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