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A deep, dark and continuous stream of mortality” is how William Farr, working in the General Register Office in England in the 1870s, described deaths in childbirth. Yet since then, particularly from the 1930s onwards, maternal deaths in the UK have plummeted, to become almost invisible today at nine deaths per 100,000 live births. How did it happen and what worked to bring this about? Can we transfer the lessons to countries such as Chad, where women face a risk of dying that is more than 180 times higher than in high-income countries?
The dream of the quick fix — the intervention, the tool, the drug, the one thing that will stop mothers dying — endures. The closest we have come to one are drugs and devices that help women to avoid giving birth: contraceptives, emergency contraceptives, abortion by medication and other safe methods, that can prevent unwanted and mistimed births.
They are effective and easy to distribute even to rural areas. A 2012 study published in The Lancet medical journal estimated that 29 per cent of maternal deaths could be averted by giving women access to family planning when needed.
But women, families and societies everywhere want and need to ensure that women and their babies survive childbirth too, just as they do in rich countries. Drugs are essential but, even with them, simple solutions elude us.
Haemorrhage, the leading cause of maternal death worldwide, can be prevented and treated using uterotonics such as oxytocin. Given preventatively, they can halve the risk of haemorrhage and should be available to all women who give birth, as a cost-effective intervention. The pharmaceuticals industry is working on producing forms that are easier to deliver to women, such as uterotonics that do not require refrigeration.
Technical and advocacy work is also under way to ensure these kinds of crucial medicines are on national essential drug lists, that supply chains function correctly to make them available at health facilities everywhere and that health workers know what to do with them.
But while uterotonics can prevent, reduce and treat haemorrhage, and have other useful applications, they can be misused — to unnecessarily induce labour early, for example, or to augment and strengthen contractions without good reason. The same drugs, then, can both help and harm women and their babies. Some women get too little, too late; others too much, too soon. Without informed, supervised and caring health workers, an apparently simple solution becomes a complex problem.
We need to look beyond materials to management. Good-quality care and effective interventions do not centre on drugs or tools, but instead require systems to work: facilities, healthcare providers, emergency medical transport, governance, information and financing.
Countries such as Cambodia are tackling this issue on multiple fronts. As a result, maternal mortality has dropped from 1,020 per 100,000 live births in 1990 to 161 in 2015. Challenges remain: in common with other low- and middle-income nations, ambulance numbers in the country are increasing rapidly, but a lack of coordination compromises their impact.
Cambodia is working to improve links between facilities, help health centre and hospital staff to review referrals, discuss improvements, standardise referral guidelines and promote provincial-level obstetric care hotlines. These efforts should help the country continue its progress in terms of maternal health and making sure women and babies are transported to the care they need. Scaling up such systems will benefit not just women and babies but also improve emergency care for everyone who needs it.
Ultimately, interventions to guarantee that women and babies survive this riskiest period need to function in complex ways. Healthy women, wanted pregnancies, caring and skilled healthcare providers and engaged and problem-solving policymakers and communities are the ultimate effective interventions. These are not “wicked problems” without solutions. They are rather hard problems that require capacity, care, integrity and thoughtfulness. That success is achievable.
Oona Campbell is professor of epidemiology and reproductive health at the London School of Hygiene & Tropical Medicine