Nicole F. Masenior
Mee Tu was from an ethnic tribe in Karenni State of northeast Burma, and with her cloth bag in tote and nearly broken flip flops she headed back into the jungle to continue her shift. The jungle was her homeland, but with an ongoing armed civil conflict, it was not a safe area for a 19 year old to live and work. Despite the dangers, as a maternal health worker trained in emergency obstetric care, she felt a sense of duty and social responsibility to assist her Karenni community. Mee Tu knew too many women who died in childbirth, because it was impossible for them to reach a healthcare facility.
Maternal death is a global health phenomenon that overwhelming affects low resource and often rural populations, such as Burma. In developing countries, where 99 percent of all global maternal deaths occur, pregnant women receive minimal prenatal care, if at all, and largely deliver without a skilled attendant. In response to this public health and human rights failure, world leaders at the Millennium Summit vowed to improve maternal health. One of the targets for this goal is to reduce the maternal mortality ratio (MMR) by three-quarters by 2015. With four years remaining , what progress has been made and what challenges remain?
To answer these questions, robust data on recent maternal mortality trends and a critical analysis of its drivers are crucial. Maternal mortality is typically measured using the ratio of maternal deaths per 100,000 live births. The United States had an MMR in 2011 of 20 (20 maternal deaths per 100,000 live births). Compare that to Afghanistan, for example, where the 2011 MMR was 880.
Methods for measuring maternal mortality have been the subject of debate, yet all the sources agree that there has been a substantial drop in maternal deaths since the MDGs were established. According to one report, maternal deaths (excluding HIV-related deaths) declined steadily from 1990 to 2011 at an annual pace of 2.8%. In the last 5 years, almost a third of this decline was in India alone.
In the past decade, just over half of all pregnant women made the WHO-recommended minimum of four visits during pregnancy. Unfortunately, in many regions of Africa and South-East Asia fewer than half of all births had skilled assistance.
The annual rate of change by country allows us to predict that 13 countries should achieve the MDG target by 2015—China, Egypt, Iran, Jordan, Libya, Maldives, Mongolia, Morocco, Peru, Samoa, Syria, Tunisia, and Turkey. An additional 15 countries will achieve the goal between 2015 and 2025.
The bottom line: the majority of maternal deaths could be averted if every woman in need had access to quality reproductive health services such as skilled attendance during pregnancy, childbirth and the postnatal period, and emergency obstetric care (EOC). Often the answer is more money, or so we think. Yes, more finances are necessary to build more hospitals, train health workers, and fund the other thousands of details instrumental in launching such an endeavor. Like many development efforts in resource poor countries, programs creating effective changes in the health system and scaling up interventions face significant hurdles: health workforce, health information systems, supply chain logistics, and managerial capacity. And above all of those challenges remains the question: will the population you want to reach actually use the services? You may spend millions of dollars on a hospital, but will people come? Are they able to come?
That question of whether the target population would use the services partly animated a project, appropriately entitled Mobile Obstetric Medics (or MOM), organized by four ethnic health organizations along the border of Thailand and Burma together with Johns Hopkins Center for Public Health and Human Rights and the Global Health Access Program. When the project began, Eastern Burma had an MMR of 721 compared to neighboring Thailand’s MMR of 48. Because of civil conflict and the restriction of health services by Burma’s military regime, the typical model of a health-center-focused approach for this area was impractical. Imagine a pregnant woman in the jungle, hiding from the military, trying to make her way to a health care facility when contractions start.
The project health workers, skilled in providing emergency obstetric care, would strap on backpacks, head into the jungle, and bring services to pregnant women, their families and the community rather than requiring people to travel to clinics. This strategy increased coverage and comprehensiveness of prenatal care and enabled more women to give birth assisted by a skilled attendant. In addition, these women received screening for hypertensive disorders of pregnancy and malaria, deworming, iron folate, and insecticide treated nets.
I left this project feeling energized by what a small amount of money and a number of dedicated and talented individuals can do. MOM focused on building capacity and empowering the community so that the community can train others and eventually expand their services, which they did.
Yes, the world set ambitious targets for reducing maternal mortality at the Millennium Summit, and the majority of countries will not meet their target. But these goals have helped focus attention on a neglected human rights tragedy. We can honor the lives of the mothers who have died during childbirth by offering our time, energy, and financial resources to reduce preventable maternal deaths whether within our country’s borders or beyond.
 Nicole Masenior is a Research Assistant in the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health.
 WHO. Trends in maternal mortality: 1990 to 2008 estimates developed by WHO, UNICEF, UNFPA and The World Bank, World Health Organization 2010, Annex 1. 2010. http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf
 Lozano R, Wang H, Foreman KJ, Rajaratnam JK, Naghavi M, Marcus JR, Dwyer-Lindgren L, Lofgren KT, Phillips D, Atkinson C, Lopez AD, Murray CJ. Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet 2011 Sep 24;378(9797):1139-65. Epub 2011 Sep 19
 Statisticians have yet to standardize the nature of the data included in the assessments, the processing of the data, and how to model it. Two sources reporting number of maternal deaths for 2005 had varied by more than 35%.
 WHO. Development Goals: progress towards the health-related Millennium Development Goals; Fact sheet N°290; May 2011; http://www.who.int/mediacentre/factsheets/fs290/en/
 Sambo1, L and Kirigia, J. Africa’s health: could the private sector accelerate the progress towards health MDGs? Int Arch Med. 2011; 4: 39. Published online 2011 November 25. doi: 10.1186/1755-7682-4-39