Tuesday, February 21, 2012

Skilled Attendance at Birth and Maternal Mortality – what the data show

My Colleague Vincenzina Santoro who is  Chief United Nations Representative for the American Family Association of New York who has researched the most recently published figures on the issue of maternal mortality writes as follows:
While maternal mortality is rare in developed countries, in poorer parts of the world many women sadly die in childbirth. When the United Nations established the eight Millennium Development Goals in 2000, one goal (MDG 5) called for the reduction by three-quarters of maternal deaths globally between 1990 and 2015 – the year all MDGs are supposed to be achieved. UN Secretary-General Ban Ki-moon used the phrase “no woman should have to pay with her life in giving life”[1] to bring home the point.

Doctors, nurses and other medical personnel emphasize that many, if not most, maternal deaths occur because there are no trained medical personnel available before, during or after childbirth.

UN Women, the new gender entity, recently published data for skilled assistance at delivery and maternal mortality ratios to indicate where – and where not – progress has been made. Data correlate significantly between the two, as shown in the tables that follow.[2]

According to this source, “Skilled assistance at delivery refers to live births attended by trained health personnel such as a doctor, nurse/midwife or community health worker.” Maternal mortality is measured as ratio of deaths per 100,000 live births (MMR). The latter data compare 1990 with 2008 but, given the difficulty in data gathering, the percentage of births receiving skilled assistance is shown as an average for 2000-2008. This makes it impossible to see if there has been an increase over time for the latter.

As shown in the table below, globally the MMR declined by one-third between 1990 and 2008 from 397 to 264 deaths, while skilled assistance was available for two-thirds of births. Not surprisingly, the MMR was generally higher where skilled assistance at delivery was lowest and vice versa. Regional data show a drop in the MMR everywhere except in the developed countries where the very low MMR has risen slightly.

In Southern Asia and Sub-Saharan Africa, where skilled assistance is below 50%, the MMR remained in triple digits. Only Sub-Saharan Africa, where skilled assistance at delivery ranged from 6% in Ethiopia to 91% in South Africa, registered a below-average decline in maternal deaths. The Middle East and North Africa registered the largest regional decline in MMR.

                                      Maternal Mortality Ratios - MMR    % Skilled Assistance at Delivery
Region                                         (mortality per 100,000 live births)            (2000-2008 average)
                                                1990            2008            % change

Developed regions                          11              14            27%                                  99%
C & E Europe & Central Asia        63              31            -51                                    97
East Asia and Pacific                    198              88            -56                                    90
Latin Amer. & Caribbean             144              85            -41                                    90
Middle East & North Africa         210              91            -57                                    79
Southern Asia                               592            275            -54                                    44
Sub-Saharan Africa                      867            646            -25                                    47
World[3]                                      397            264            -34                                    67

The MMR improved in 143 of the 171 countries for which data were available, or 84% of all reporting countries. In 1990 there were 16 countries with a MMR of 1,000 or more but by 2008 the number had come down to four: Afghanistan with a ratio of 1,400 followed by Chad and Somalia at 1,200 then by Guinea Bissau at 1,000. Both Afghanistan and Chad had skilled assistance at delivery of only 14%.

As indicated below, there were 15 countries that had a MMR of 500 or higher in 2008, all but two located in Sub-Saharan Africa. Since 1990, some made progress but others did not. Only Laos stands out for halving its MMR.

                        Maternal Mortality Ratios – MMR              % Skilled Assistance at Delivery
Country            (mortality per 100,000 live births)                        (2000-2008 average)
                                    1990                        2008

Afghanistan                        1,700                        1,400                                                14%
Chad                                   1,300                        1,200                                                14
Somalia                              1,000                        1,200                                                33
Guinea-Bissau                    1,200                        1,000                                                39
Liberia                                1,100                           990                                                46
Burundi                              1,200                           970                                                34
Nigeria                                1,000                          840                                                39
Mali                                    1,200                           830                                                49
Niger                                  1,400                           820                                                33
Tanzania                                880                           790                                                43
Sudan                                    830                           750                                                49
Guinea                                1,200                           680                                                46
Angola                                1,000                           610                                                47
Laos                                    1,200                           580                                                20
Rwanda                               1,000                          540                                                52

The countries with the lowest MMR in 2008 were Greece with two and Ireland with three. There were six countries with a ratio of five: Austria, Belgium, Denmark, Italy, and Sweden.

Curiously, three of the most developed countries saw the ratio rise: the United States from 12 to 24, the United Kingdom from 10 to 12 and Switzerland from 8 to 10.

Other countries of interest: in Russia, known for having the world’s highest abortion rate, the MMR has declined from 74 to 39 with 100% skilled assistance at delivery. China’s MMR came down from 110 to 38 with 98% skilled assistance at delivery.

In conclusion, the one-third reduction in worldwide MMR in 18 years is notable, but the three-fourths decline targeted by 2015 appears illusory. Nonetheless, on a country-by-country basis, individual success may be within reach for at least a few countries. In the period under review, four countries already have cut the MMR by three-fourths: Estonia (from 48 to 12), Bhutan (from 940 to 200), Iran (from 150 to 30), and Maldives (from 510 to 37).