EDITORIAL

Help across borders

Most obstetricians have known the ultimate failure: loss of a mother during pregnancy or childbirth. Whether the cause is postpartum hemorrhage, preeclampsia, infection, or trauma, such a death is devastating to all those involved. No matter how hard the medical team fights to save the mother's life, each individual no doubt questions what more he or she could have done. And then there is the plight of the motherless child and the woman's husband, left to raise the newborn on his own. The tragedy of maternal mortality is overwhelming.

During the early 20th century, maternal deaths were fairly common in the United States: In 1930, 670 maternal deaths occurred per 100,000 live births. By 1950, that number had dropped to 83.3 deaths per 100,000 live births, and the downward trend continued until 1982. From 1982 to 1996, the maternal mortality ratio remained stable at approximately 7.5 maternal deaths per 100,000. This sharp decline in maternal mortality in a country with a diverse population is a real tribute to modern medicine and better access to care. Nevertheless, maternal deaths remain underreported and our data collection system still needs some refinement.

Looking at maternal mortality on an international scale, available data suggest that recordkeeping in some countries is exemplary, whereas underreporting is a problem in some areas. One has to applaud the United Kingdom for its system of confidential inquiries into such deaths. Ninety-nine percent of maternal deaths there are reported, largely because the data collected are not admissible in a court of law.¹ In contrast, a recent analysis of maternal mortality in the Netherlands from 1983 to 1992 suggests that while the officially reported rate was 7.1 per 100,000 live births, the actual rate was at least 9.7 per 100,000 live births.² Also, some countries have made significant progress in reducing perinatal mortality, whereas their rates of maternal mortality remain relatively high. One example is Japan, with a recently recorded maternal mortality rate of 8 to 9.5 per 100,000,^3,4 compared with a perinatal mortality rate of 5 per 1,000 live births.⁵

Sadly, there are countries in the world, such as Mozambique, where the number of maternal deaths exceeds 1,000 per 100,000 live births.³ In other developing nations, such as Ghana and Uganda, the death rate is lower but still many times that in developed countries. Collectively, 1,800 maternal deaths occur a day throughout the world, or more than one maternal death every 60 seconds.

There are many factors that contribute to high rates of maternal mortality, including lack of medical personnel, poor access to hospitals, lack of antibiotics, and no blood banking facilities. In many countries, of course, the most significant problem is little or no access to prenatal care. Problems such as hemorrhage, infection, preeclampsia, trauma, and abuse still claim many lives. Every year, many women die as a result of illegal abortions, although the exact number remains undocumented. The mortality due to postpartum hemorrhage could be drastically reduced with proper care and access to blood transfusions. With skilled medical personnel and antibiotics available, many septic maternal deaths could be prevented.

The International Federation of Gynecology and Obstetrics (FIGO) is working to identify the most cost-effective way to save mothers' lives by mobilizing the obstetric and gynecologic community throughout the world. Begun in 1997, the Save the Mothers Fund is designed to combat runaway maternal mortality worldwide and to improve obstetric and gynecologic care by partnering professional obstetric and gynecologic societies from five developed countries with their local counterparts in eight developing countries. In Phase I of the program, needs assessment missions were undertaken by Canada in partnership with Uganda, the UK with Pakistan, Italy with Mozambique, and Sweden with Ethiopia. The US has partnered with Central America, where in Guatemala, Honduras, Nicaragua, and El Salvador alone, more than 1,000 women died due to complications of childbirth in 1998.

Initial results of the Save the Mothers Fund were presented last month in Washington, DC, at the XVI FIGO World Congress. Physicians from the developed countries traveled to target regions to meet with their counterparts and to assess the regions' needs for possible solutions. By our standards, the improvement targets may seem insignificant, but in many developing countries, obstetric care falls below even the lowest standards. In Ethiopia, for example, there is one hospital for 2.5 million residents, whereas the international minimum standard is one hospital for every 500,000 residents.

Although the Save the Mothers Fund has not yet succeeded in reducing the number of maternal deaths in developing countries, the quality of health care delivery is being improved. In many developing nations, poverty and lack of medical facilities are the true underlying causes of high rates of maternal mortality. The initial steps for improvement involve rudimentary but critical analysis focusing on delivery of emergency care rather than routine or preventive services. The first steps undertaken by the Save the Mothers Fund were to evaluate such basics as how the decision is made to seek emergency care for a mother in trouble, how long it takes to get into an emergency facility, and time elapsed before care is received. The obstetric and gynecologic partnerships are a creative way to lower maternal mortality in the future and serve as demonstration projects for other countries. In Phase II of the program, each team will develop, execute, and test a demonstration project in a developing country.

In the US, despite a government budget surplus and a booming economy, many less fortunate Americans still lack health insurance and access to preventive medical care. It may seem strange that we are going abroad to help others when there is still so much to do here at home, but we do have the necessary resources and expertise. I am very proud that my colleagues are participating in the Save the Mothers Fund.

There is a great disparity between maternal mortality in developed and developing countries. The gaps are in information, availability of trained personnel, and access to facilities. The prospects for bridging the information gap with telecommunications are relatively bright. But the gaps in trained personnel and medical facilities are not going to be easy to address because that effort takes time and money, both of which are in extremely short supply.

It may take many years to reduce maternal mortality rates in developing countries to levels comparable to that in the US or other developed countries, but we've got to start somewhere and to do it now. Improving the quality of life in just one place in the world ultimately will have a positive impact for everyone in our global health-care community.

REFERENCES

1. de Swiet M. Maternal mortality: confidential enquiries into maternal deaths in the United Kingdom. Am J Obstet Gynecol. 2000;182:760-766.

2. Schuitemaker N, Van Roosmalen J, Dekker G, et al. Underreporting of maternal mortality in The Netherlands. Obstet Gynecol. 1997;90:78-82.

3. Data taken from http://www.unicef.org. Web site accessed September 20, 2000.

4. Nagaya K, Fetters MD, Ishikawa M, et al. Causes of maternal mortality in Japan. JAMA. 2000;283:2661-2667.

5. Sakamoto S, Terao T. How to lower perinatal mortality? Perinatal care in Japan. Croat Med J. 1998;39:197-207.

John T. Queenan, MD, Editor in Chief, is Professor of Obstetrics and Gynecology, Georgetown University School of Medicine, Washington, D.C.

 

John Queenan. Editorial: Help across borders. Contemporary Ob/Gyn 2000;10:8-11.