Maternal Survival 2 Strategies for reducing maternal mortality: getting on with what works

Abstract

The concept of knowing what works in terms of reducing maternal mortality is complicated by a huge diversity of country contexts and of determinants of maternal health. Here we aim to show that, despite this complexity, only a few strategic choices need to be made to reduce maternal mortality. We begin by presenting the logic that informs our strategic choices. This logic suggests that implementation of an eff ective intrapartum-care strategy is an overwhelming priority. We also discuss the alternative confi gurations of such a strategy and, using the best available evidence, prioritise one strategy based on delivery in primary-level institutions (health centres), backed up by access to referral-level facilities. We then go on to discuss strategies that complement intrapartum care. We conclude by discussing the inexplicable hesitation in decision-making after nearly 20 years of safe motherhood programming: if the fi fth Millennium Development Goal is to be achieved, then what needs to be prioritised is obvious. Further delays in getting on with what works begs questions about the commitment of decision-makers to this goal. is a deceptively simple phrase, often used in international advocacy aiming to reduce the burden of maternal mortality in developing countries. Strategies that aff ect this burden have proved to be among the most successful eff orts to address a specifi c cluster of causes of death, with developed and some developing countries having reduced the risk of maternal death by 90–99%. The 1000 deaths per 100 000 livebirths or greater risk of maternal mortality seen in the past in developed countries and now in the poorest developing countries, has been reduced to as low as 10 per 100 000. Although falling short of eradication of maternal death, these impressive reductions are similar to the eff ectiveness of such undisputed public-health interventions as polio immunisation (95%) or oral contraception (97%). At the same time, however, the substantial obstacles in poor countries to achievement of the maternal mortality target of Millennium Development Goal (MDG) 5 are well acknowledged, 2,3