What next for maternal mortality in a post-MDG world?
Success lies behind dealing with wider determinants to health
The millennium development goals (MDGs), a set of eight time bound targets focusing on international development, expire in 2015. Three of the goals set in 2000 are about improving health outcomes in developing countries, with one goal focused on improving maternal health outcomes (MDG 5). The other two health oriented goals aim to reduce child mortality and HIV/AIDS, malaria, and other diseases.
The World Health Organization reported that 289 000 women died from preventable complications of pregnancy in 2013, which works out at about 800 women a day. The strategies that have been used to reduce maternal mortality need to be evaluated to find which ones work best, and these should be implemented in the post-MDG era. The question of how the MDG agenda should continue was discussed at the 2012 United Nations Conference on Sustainable Development held in Rio, Brazil. This article reviews what has been achieved and what remains to be achieved for MDG 5.
Overview of MDGs
The MDGs are eight developmental objectives established in the United Nations Millennium Declaration of 2000. They aim to reduce global inequalities in areas as diverse as healthcare, education, and basic human rights.
The goals focus on developing countries, with developed nations providing aid, debt relief, and development assistance. They are supported financially and on the ground by non-governmental organisations (NGOs).
What policies have been implemented to reduce maternal mortality?
Maternal mortality is one of the leading health issues affecting low and middle income countries. In 1990, there were 543 000 maternal deaths worldwide, 99% of which were in low and middle income countries. MDG 5 was conceived to try and reduce this vast inequality. It had two targets: to reduce the maternal mortality ratio by 75% and to achieve universal access to reproductive health.
Efforts to reduce maternal mortality have focused mainly on two key strategies: improving access to skilled birth attendants, and increasing the availability of emergency obstetric care. These policies have particular relevance in low and middle income countries because many mothers living in rural areas go through pregnancy with care provided solely by traditional birth attendants. These attendants, who have long been the mainstay of maternal care for rural communities, are not clinically trained and lack integration with the national health service. Although most people in developed nations chose to live in urban centres, 70% of the world’s poor live in rural areas. Given that most maternal deaths occur within 24 hours of delivery, and are largely unpredictable, securing women’s access to emergency obstetric care is vital to reducing maternal deaths.
Case study: success in Sri Lanka
One country that has achieved remarkable improvements in maternal outcomes is Sri Lanka—one of only a few countries likely to achieve MDG 5 by 2015. Although the lifetime risk of maternal death in Sri Lanka is greater than in developed countries (one in 1400 compared with one in 3800), it is much lower than the regional average for southern Asia of one in 160. How has Sri Lanka achieved this?
Sri Lanka has introduced a successful programme of increasing access to skilled birth attendants. Skilled birth attendants are trained for 18 months and are expected to cover a population of about 4000 women. Their roles include attending deliveries, providing antenatal and postnatal care, and running family planning services. By 2007, 99.5% of deliveries in Sri Lanka were attended by a skilled birth attendant. Hemantha Senanayake, professor of obstetrics and gynaecology at the University of Colombo, Sri Lanka, says that this initiative has only been successful because of a “political will over many decades that has supported investments in preventive health strategies.”
The wider picture
The Sri Lankan government recognised early on that improving maternal outcomes would be impossible without dealing with the root causes and wider determinants of maternal mortality. Factors such as education and infrastructure have been tackled with credibility. A policy of free education for all has resulted in youth literacy rates of 99% for females and 97% for males. Senanayake says that 60 years of free education, without discrimination, has been crucial for “ensuring the empowering of women.” Education has encouraged more women to use healthcare provision rather than relying on unskilled traditional birth attendants. There have been similar improvements in infrastructure provision. A state financed programme to improve the road network now means that every home throughout the country is within 2.2 miles of a modern healthcare facility. Sri Lanka’s maternal mortality rate is now noticeably lower than the ratios of similar countries. In fact, with a maternal mortality ratio of 29, Sri Lanka is now closer to developed nations than are low and middle income countries (maternal mortality ratios of 16 and 230, respectively). Total health expenditure as a percentage of gross domestic product per capita is still only 3.3%, lower than the average for low income countries, of 5.3%. Even this represents an increase by a factor of 4 in Sri Lanka’s expenditure on health between 1995 and 2012. 
Case study: struggles in Nigeria
Although Nigeria makes up only 1% of the global population, it accounts for 14% of all maternal deaths worldwide. With a lifetime risk of death during pregnancy of one in 29, compared with a risk of one in 3800 for developed nations, Nigeria is struggling to achieve MDG 5. This cannot be attributed to a lack of spending on health alone as Nigeria’s per capita total expenditure on health has been consistently greater than that of Sri Lanka’s.
Health system inequality
The underlying problem is one of rural-urban inequality. The health service in Nigeria is a three tiered system, comprising primary healthcare in rural areas and secondary hospitals and tertiary hospitals at the national level. Primary care is underfinanced in rural areas, and it is not always easy to refer patients to secondary care services. Given that 54% of Nigeria’s population live in rural areas, this weakness in primary care provision excludes a large proportion of the population from accessing adequate healthcare. This is particularly pertinent to maternal outcomes, as the most common cause of maternal death (postpartum haemorrhage) is unpredictable, yet treatable if identified and managed without delay.
In 2009 the Midwives Service Scheme was introduced in Nigeria, to improve rural access to emergency obstetric care and skilled birth attendants. The scheme allocates skilled midwives, proficient in emergency care, to primary care centres in rural areas of the country. This should provide access to 24 hour skilled maternity care in rural areas, with easy access to a hospital if required. This project has the potential to transform maternal care in Nigeria, but data on its impact are currently lacking.
Has MDG 5 been a success?
Despite some success stories in reducing maternal mortality, vast inequalities still exist. Peter Hill, associate professor at the Australian Centre for International and Tropical Health, says the MDGs have helped to “focus attention, provide a common metric for measuring change and galvanise activity, increasing funding for these areas.” However, he argues that because of their focus on a “limited selection of priority diseases other priorities have been neglected, and broader strategies in the development of comprehensive health systems have been marginalised.”
Although the MDG agenda has limitations, it has been a catalyst for change in the global health arena. Jenny Cresswell, an epidemiologist at the London School of Tropical Medicine and Hygiene, says an “advantage of the MDGs is that the need to get data to track progress has meant there have been huge investments in improving the quality and frequency of household surveys to measure health outcomes.” Even though many countries are off track to meet the 75% reduction in maternal mortality, there are now better systems in place to analyse the progress being made to combat maternal mortality and other health outcomes.
Where should the focus be now?
The sustainable development goals drafted at the United Nations Conference on Sustainable Development in 2012 will form the backbone to the post-2015 development agenda. Conceived as a means to build on the foundation laid by the MDGs, they constitute 17 goals and 169 targets, with SDG 3 focused on health. Target 3.1 is to reduce the global maternal mortality rate to less than 70 per 100 000 live births by 2030. This new goal seems inadequate. When countries such as Sri Lanka have already achieved a maternal mortality ratio of less than 70, any new targets must be focused on those countries that have thus far struggled to achieve MDG 5. These countries are almost exclusively in a belt across central southern Africa (see figure), which indicates that a targeted approach for certain continents, regions, and countries should be considered. 1
The role for students in shaping the sustainable development goals
Although the sustainable development goals were drafted by the Open Working Group of senior representatives from multiple countries around the world, we as current medical students will likely be the ones implementing the policy in the coming years. Nathan Cantley is a fourth year medical student at Belfast and chair of the Post-2015 National Working Group for Medsin-UK, which has been putting forward the student voice on what should happen once the MDGs expire. He says there are several ways students can have input in the global health agenda. You can start small by looking out for and contributing to hashtags on Twitter such as #post2015 #sdgs #action2015. “If you want to get involved in shaping the global health agenda,” Cantley adds “international organisations such as the Major Group for Children and Youth puts together position papers and statements that are read out at UN meetings in New York where the SDGs are being debated and they are always seeking new members to contribute.”
Maternal mortality is one of the main health problems affecting developing countries. MDG 5, although it has not achieved universal success, has helped to focus global attention on the plight of pregnant women globally. The examples of Sri Lanka and Nigeria show that although it is essential to develop quality maternity care services, this alone is not sufficient. Sri Lanka has gone further to deal with the broader issues behind maternal mortality—such as infrastructure and access to education—and as a result it has seen a large reduction in its maternal mortality ratio.
Although the MDG agenda will formally come to an end this year, the underlying problems still remain. Going forwards there must be an individualised approach to support countries that require help, as well as a recognition that improving health outcomes depends on the wider socioeconomic determinants to health.Simon Prinsley, fifth year medical student
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
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Cite this as: Student BMJ 2015;23:h3179