Deaths during childbirth may have dropped sharply worldwide — or maybe not
Deaths of women during childbirth dropped by a startling 35% from 1980 to 2008, from more than half a million yearly to 343,000, according to a new analysis reported online this week in the journal Lancet.
Or maybe not, depending on whom you listen to. The report, coming on the eve of a major New York City conference on maternal health, has provoked widesrpead criticism and confusion, as well as conflicting media reports.
The new report, by researchers from the University of Washington and the University of Queensland in Australia, is startling because most previous studies, including a United Nations report released only two years ago, have indicated that the rate has remained fairly steady at about half a million, with only modest improvements in some areas. But the new report by Dr. Christopher Murray of Washington and his colleagues suggests that the rate has been dropping by an average of about 1.4% per year since 1980. If they are correct, that is very good news because it means that countries are making a concerted effort to reduce maternal deaths.
But an analysis released about the same time by a group called Countdown to 2015 — so-named because two of the United Nations' Millennium Development Goals for 2015 include significant reductions in both maternal and child deaths before that year — says its own analysis shows that 350,000 to 500,000 women still die in childbirth each year, with the number probably at the higher end of the range.
Overlaying the dispute on numbers is a political disagreement, fueled by that most contentious of topics: money. Countdown to 2015 and other groups say that an additional $16 billion in donor funds over the $4 billion currently received will be required by 2015 to help meet the development goals. But good news about a reduction in mortality might put a crimp in their plans. Typically, when success is being achieved in any public health area, there is less urgency to donate new funds to continue the effort. Thus, the editor of the Lancet, Dr. Richard Horton, noted in an editorial that he had been pressured by some — as yet unnamed — maternal health advocates to delay publication of Murray's report until September, after the end of the current fundraising season.
Murray and his colleagues say they are confident in their figures because they have compiled a lot more data than has been possible before, from vital registration data, censuses, surveys and autopsy studies. Using this data, they have generated a maternal mortality ratio (MMR) for each country, as well as for the world as a whole. An MMR is the number of women who die during childbirth for every 100,000 live births. Globally, the MMR fell from 422 in 1980 to 251 in 2008, they reported. The highest MMR was 1,575 in Afghanistan, while the lowest was four in Italy. The U.S. ranked 39th worldwide, with an MMR of 17.
More than 80% of all maternal deaths were concentrated in 21 countries in 2008, while 50% were in only six countries: India, Nigeria, Pakistan, Afghanistan, Ethiopia and the Democratic Republic of the Congo. Despite Murray's observed reduction in maternal mortality, the team concluded that only 23 countries were on track to achieve their target of lowering MMR by 75% between 1990 and 2015. Among those doing the best are Egypt, China, Ecuador and Bolivia.
Among developed countries, the U.S., Canada and Denmark have been trending in the opposite direction, according to the study. The MMR in the United States has increased from 12 in 1990 to 17 in 2008, a 42% increase. Part of the increase may be due to changes in the way such deaths are reported, the authors concluded, but that does not explain why deaths here are occurring at double the rate of in Britain, triple the rate in Australia and four times the rate in Italy.
The analysis found that nearly one in five deaths in 2008, a total of 61,400, were associated with HIV infections. The high incidence of HIV in sub-Saharan Africa is a major reason why many countries there are having difficulty lowering their MMR.
Some possible solutions to the problem of maternal deaths are simple "if the will and the funds are present," said Dr. Flavia Bustreo, director of the Partnership for Maternal, Newborn & Child Health, a group of more than 300 organizations that plays a major role in Countdown to 2015. For example, if women were to go to clinics with trained staff or midwives and proper equipment, an estimated 50% of mothers and newborns could be saved, she said. If mothers received adequate prenatal care, up to two-thirds of them could be rescued.
Reducing stigma linked to childbirth and deaths is also important. In many parts of Southeast Asia, for example, childbirth is considered dirty and women are forced to deliver in cowsheds, where they must remain for a month. Cords are often cut with dirty tools, leading to infections. Babies with pneumonia do not get antibiotics. And families know that many mothers and babies will die, so they simply accept it and do not report it.
"Millions of babies die without people realizing it can be different," said Dr. Joy Lawn of Saving Newborn Lives/Save the Children. "This is not high tech. Up to 3 million newborns can be saved each year with simple approaches" like using clean tools, providing antibiotics to treat pneumonia and kangaroo care, where the mother acts as an incubator for her preterm infant.
— Thomas H. Maugh II