Elsevier

The Lancet

Volume 368, Issue 9543, 7–13 October 2006, Pages 1284-1299
The Lancet

Series
Strategies for reducing maternal mortality: getting on with what works

https://doi.org/10.1016/S0140-6736(06)69381-1Get rights and content

Summary

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 effective intrapartum-care strategy is an overwhelming priority. We also discuss the alternative configurations 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 fifth 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.

Section snippets

Stripping complexity to reveal strategic choices

Making strategic choices requires decision-makers to be explicit about the values attached to alternative outcomes, since such values affect the target group and the packages of appropriate interventions. Some means of distribution are capable of delivering multiple packages aimed at multiple outcomes, and these opportunities are often taken for pragmatic reasons. This approach can result in a strategy that seems unfocused, with several valued outcomes and no sense of priority. As a result,

Intrapartum-care strategies must be the priority

Figure 2 shows the strategic options aimed at reducing maternal mortality. Some of these options share the same target group, whereas others are complementary and focus on different women.

Most maternal deaths occur during labour, delivery, or the first 24 h postpartum, and most complications cannot be predicted or prevented (see the first report in this series). Individual complications are quite rare, and timely diagnosis and appropriate intervention requires considerable skill to prevent

Strategies that complement those targeted at the intrapartum period

Intrapartum-care strategies are acknowledged as the priority focus for reduction of maternal mortality, but the role of complementary strategies with different target groups, such as pregnant women or women not desiring pregnancy, are also important to consider. We recognise the potential for four such strategies—antenatal care, postpartum care, family planning, and safe abortion—but also comment on broader-based strategies which relate to women's health and development per se.

Whereas an

Conclusions

In this paper we aim to replicate for maternal survival what other specialties within international public health have done so well—to strip away the complexities about what to do, and thereby remove excuses for inaction. And like in other specialties, such stripping away involves simplification of the issues, making heroic assumptions, and use of bold claims and language. Of course the reality is more complex: decision-making for scarce health resources is a matter of politics, values, and

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