May 10, 2008

‘Maternal mortality tends to be under-reported since people in developing countries often die outside the health system’
 

— Mohammad Iqbal Kahut

World Health Organisation
 

Dr Mohammad Iqbal Kahut is the National Programme officer, MPS (Making Pregnancy Safer), at the WHO, Islamabad. In this interview with Sci-tech World, he provides us with extensive information on maternal mortality. Excerpts from the interview...

What is your take on maternal health is Pakistan?

While in most cases having a baby is a positive and fulfilling experience, pregnancy and childbirth can also be associated with suffering, ill health or even death. Interventions that can prevent maternal and newborn mortality from major causes are known and can be made available even in resource-poor settings.

This is where MPS or Making Pregnancy Safer comes in. WHO or the World Health Organisation provides technical support to Pakistan, as well as other countries for maternal health through its MPS department. The objective of MPS is to ensure that governments and partner agencies receive guidance and technical support. MPS interventions help strengthen health systems, including improving access to and quality of health services, and enhance individuals’, families’, and communities’ capacities to respond better to needs, to ensure that women and their newborn babies have access to and use the care they need when they need it.

How is the situation different if you compare Pakistan with the rest of the world?

Every year around eight million women in the world suffer from pregnancy-related complications and over half a million die. In developing countries one woman in 16 may die of pregnancy-related complications compared to one in 2,800 in developed countries. What is sad is the fact that these deaths are preventable.

In Pakistan 16,500 women die each year due to complications of pregnancy and child birth, and 40,000 infants die in their first year of life. In Pakistan, Maternal Mortality Ratio (MMR) officially quoted is 200 per 100,000 live births which, if you come to think of it, is much better than previous reports of 500 per 100,000 live births.

What is the Maternal, Neonatal and Child Health (MNCH) programme?

The Maternal, Neonatal and Child Health (MNCH) Programme is a programme of government of Pakistan developed with technical assistance of WHO and other partners for achieving Millenium Development Goals (MDGs). WHO is committed to assisting the government in its attempt to implement the full spectrum of interventions necessary to address the MNH issues. The programme will ensure progress toward achieving the MDG in maternal and child health.

What areas does it cover?

In Pakistan infants and newborn babies die mainly due to birth asphyxia, intra-uterine growth retardation, acute respiratory infections and diarrhoea. All of these causes are both preventable and treatable. A majority of births occur at home and are attended by untrained traditional birth attendants. The major causes of maternal deaths are haemorrhage, puerperal sepsis, toxaemia of pregnancy and obstructed labour. Several studies on maternal mortality have identified the need for addressing the three delays in accessing emergency obstetric care and for integrated efforts for saving mothers’ lives both at the community and hospital level.

Short-term and localised programmes and projects have failed to achieve significant and sustainable improvements in MNCH indicators. Such improvements can only be achieved at national level through a comprehensive, focused and effective programme that is owned and managed by the districts, and is customised to meet the district’s specific needs.

Furthermore, the MNCH programme is a comprehensive programme aiming at strengthening, upgrading and integrating ongoing interventions and introducing new strategies. The programme will a strengthen district health systems through improvement in technical and managerial capacity at all levels and upgrading institutions and facilities, streamline and strengthen services for provision of basic and comprehensive emergency obstetric and newborn care (EmONC), integrate all services related with MNCH at the district level, introduce a cadre of community-based skilled birth attendants, and increase demand for health services through targeted, socially acceptable communication strategies.

What are WHO’s goals and targets as far as MNCH in Pakistan is concerned?

The overarching programme goal is to improve accessibility of quality MNCH services through development and implementation of an integrated and sustainable MNCH programme at all levels of the healthcare delivery system. The programme will ensure progress toward achieving the MDGs in maternal and child health. Specific objectives are:

1. To reduce the under five mortality rate to less than 65 per 1000 live births by the year 2011 (Target 2015: 45/1000)

2. To reduce the newborn mortality rate to less than 40 per 1000 live births by the year 2011 (Target 2015: 25/1000)

3. To reduce the infant mortality rate to less than 55 per 1000 live births by the year 2011 (Target 2015: 40/1000)

4. To reduce maternal mortality ratio to 200 per 100,000 live births by the year 2011 (Target 2015: 140/100,000)

Progress toward the MDG targets will be monitored through third-party evaluations, national surveys such as the Pakistan Demographic Survey, regular monitoring of other aspects of the health system in the country, health management information system and other service statistics.

What is our biggest challenge as far as improving maternal mortality is concerned?

Maternal morality rates and ratios are difficult and expensive to obtain and are often inaccurate because of under-reporting and misclassification. Maternal mortality tends to be under-reported because people in developing countries often die outside the health system, which makes accurate registration of deaths difficult.

Maternal mortality is also misclassified, because health workers may not know why a woman died, or whether she was or had recently been pregnant. Deaths are sometimes intentionally misclassified, especially if they are associated with clandestine abortions.

Methods used to calculate maternal death rates are often complex and costly to use. The actual number of maternal deaths in a specific place at a specific time is relatively small. Therefore, very large populations must be surveyed in order to get accurate estimates, which is costly. The relative infrequency of maternal deaths over a short period also means that the rates will appear to jump around, making interpretation of trends over time difficult. In addition, some of the poorest countries do not have adequate vital registration systems.

There is widespread lack of awareness about the Millennium Development Goals, even among maternal and child health programme managers, and the adoption of the goals has not translated into action to achieve them. National policies on maternal and neonatal health are still lacking in most of the countries.

With the current maternal and child mortality trends, the MDGs are unlikely to be achieved, unless commitments, intensive efforts and national plans are made and translated into action, including resources allocation. Such efforts and plans should target the strengthening of health systems, expansion in the coverage of effective integrated interventions and recognition of the essential role of community participation.

The current tendency to fund vertical disease-specific programmes has dramatically shifted resources from maternal and child health. This tendency may lead to neglect of integrated strategies that aim both to strengthen the health system and to build capacity of the human resources that are essential to support and sustain progress towards the MDGs.

The current level of health expenditure, especially in the low-income countries in the region, which are those with the highest child and maternal mortality, is insufficient to support strategies and actions necessary to achieve the MDGs. The serious reduction in WHO allocations to child and maternal health at regional level has also adversely affected the scaling up of the implementation of effective related interventions.

Maternal and child health-related data and information are still scarce in most countries of the region. Even when available, these data are either of poor quality or their use in decision-making and planning is remarkably limited.

—R. B.