Approaches to reduction of maternal mortality in resource-limited settings

INTRODUCTION — In 2000, 189 nations pledged to free people from extreme poverty and multiple deprivations [1]. The specific target for maternal health was to reduce each country's 1990 maternal mortality ratio (MMR) by three quarters by 2015 [2]. This goal was expanded by the United Nations Sustainable Development Goals to reduce the global MMR to less than 70 per 100,000 live births by 2030 [3].

This will require the involvement of health systems, communities, and families globally, and necessitate addressing political, economic, social, technical, and environmental factors contributing to maternal morbidity and mortality.

For pregnant women, optimizing intrapartum care appears to be the single most important intervention for reducing maternal mortality in both high-income countries (HIC)/resource-rich settings and middle/low-income countries (MIC/LIC)/resource-limited settings [4,5]. The leading causes of mortality in these women are hemorrhage, hypertensive disorders, infection, obstructed labor, and complications from unsafe abortions. In LICs, major causal factors are inadequate prenatal, intrapartum, and postpartum care by skilled birth attendants and inadequate facilities, equipment, and services. For nonpregnant women, family planning is the single most important intervention for reducing maternal mortality.

This topic will discuss approaches to reduction of maternal mortality in the poorest parts of the world. In these areas, dying as a result of pregnancy or childbirth is approximately 1 in 6 compared with approximately 1 in 30,000 in Northern Europe [6]. An overview of principles of maternal mortality, including strategies for reduction in high income countries, is reviewed separately. (See "Overview of maternal mortality".)

In this topic, when discussing study results, we will use the gender terms as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transmasculine and gender-expansive individuals.

SERVICES — One model suggested a stepwise approach that coupled improved family planning with incremental improvements in skilled attendance, transport, referral, facilities, and intrapartum care would prevent three of four maternal deaths [7]. These interventions are discussed below.

Family planning — Family planning is one of the four pillars of the Safe Motherhood Initiative to reduce maternal death in resource-limited countries, and may be the single most important intervention for achieving this goal. Family planning can reduce mortality in women in several ways:

●Reduction in unwanted pregnancy, which:

•Decreases pregnancy-related mortality.

•Decreases abortion-related mortality.

•Delays first pregnancy in adolescents. Pelvic development may be incomplete in adolescents, resulting in cephalopelvic disproportion. In nutritionally restricted environments, the nutritional requirements of growing adolescents appear to compete with the growth needs of the fetus, potentially resulting in stunting of both maternal and fetal growth [8,9].

•Reduces high parity, which is associated with an increased risk of life threatening complications such as placenta previa and postpartum hemorrhage. (See "Grand multiparity".)

•Reduces closely spaced pregnancies, allowing the mother to recover between pregnancies.

●Noncontraceptive health benefits (eg, reduction in ectopic pregnancy and some cancers) (table 1).

The potential benefit of contraception for averting maternal deaths worldwide was evaluated in a study that extracted data from the Maternal Mortality Estimation Inter-Agency Group database, the United Nations (UN) World Contraceptive Use 2010 database, and the UN World Population Prospects 2010 database [10]. The model estimated that 342,203 women died of maternal causes in 2008, but that contraceptive use averted an additional 272,040 deaths (95% CI 127,937-407,134), thus use of contraception resulted in a 44 percent reduction in maternal death. The model also predicted that satisfying unmet needs for contraception could prevent another 104,000 maternal deaths per year (29 percent reduction). Another model also affirmed that promotion and facilitation of family planning should be the initial approach for reduction of maternal mortality in low-income countries (LICs) [7].

Unsafe abortion is another major cause of maternal death that ideally is averted by protection against unwanted pregnancy. In 2005, it was estimated that 70,000 women died yearly as a result of unsafe abortion, accounting for one in eight (13 percent) maternal deaths [11]. Almost all of these deaths occurred in Sub-Saharan Africa, South Central Asia, Latin America and the Caribbean, and some Eastern European countries; a negligible number occurred in Southern and Western Europe, North America and China. When unwanted pregnancy does occur, maternal death is rare where abortion is legal and access is nonrestrictive, and when pregnancy terminations are carried out by skilled health professionals using effective methods in hygienic conditions [12]. (See "Overview of pregnancy termination", section on 'Maternal mortality'.)

Short interpregnancy intervals also appear to increase the risk of maternal mortality, and can be avoided by use of contraception. A Latin American study including 456,889 women reported interpregnancy intervals of less than six months were associated with an increased risk of maternal death compared with women with interpregnancy intervals of 18 to 23 months (adjusted odds ratio 2.5, 95% CI 1.2-5.4) [13]. Four smaller studies of variable quality also found an association between short interpregnancy interval and maternal death, but the trend was not statistically significant [14]. (See "Interpregnancy interval: Optimizing time between pregnancies".)

Skilled birth attendants — More than two-thirds of women worldwide give birth at home, often with a traditional birth attendant who is not a trained health-care provider. The availability of a skilled attendant implies the presence of a health professional with midwifery skills, as well as resources to enable them to perform capably, including access to higher levels of obstetric care in case of complications requiring surgery or blood transfusions [15].

Ensuring that all women give birth with a skilled attendant is considered one of the key strategies for reducing maternal mortality [4,16]. As of 2010, approximately 66 percent of the world's countries have achieved a target of 80 percent of births attended by a skilled provider [17].

There is some evidence that a skilled attendance strategy contributes to a reduction in maternal mortality in poor countries:

●In a study from rural Bangladesh that compared maternal mortality ratio (MMR) in villages where trained midwives were posted and asked to attend as many home-deliveries as possible versus neighboring villages with comparable baseline MMR and no trained midwives, MMR became significantly lower in the intervention villages than in the control villages after three years (140/100,000 versus 380/100,000 live births) [18].

●A 2011 systematic review and meta-analysis of the effectiveness of strategies incorporating providing training and support of traditional birth attendants showed a statistically nonsignificant reduction in maternal mortality (three randomized trials, relative risk [RR] 0.79, 95% CI 0.53-1.05; three nonrandomized studies, RR 0.80, 95% CI 0.44-1.15) [19].

●In a modeling study using the Lives Saved Tool for high-burden, low-income and middle-income countries, universal coverage of midwifery care with both family planning and interventions for maternal and newborn health could avert 83 percent of all maternal deaths, stillbirths, and neonatal deaths [20]. The included countries account for 97 percent of maternal and 94 percent of neonatal mortality [21,22].

Availability of skilled birth attendants alone will not reduce maternal mortality if they are not utilized [23,24]. In a study from Nigeria, which has a very high MMR (>1000/100,000 live births in 2008), the reasons for low utilization of antenatal and delivery care among women with recent pregnancies were: custom, lack of perceived need, distance, lack of transport, lack of permission, cost, and/or unwillingness to see a male doctor [23]. Therefore, when designing and implementing interventions to improve obstetric care, women need to be educated about safe pregnancy and delivery, their economic and geographic accessibility issues need to be addressed, and their social and cultural beliefs and practices need to be respected.

Emergency obstetric care — The World Health Organization (WHO) considers the ability to provide the following seven "basic" services requisite for provision of emergency obstetric care [25]:

●Administer parenteral antibiotics

●Administer uterotonic drugs

●Administer magnesium sulfate to women with preeclampsia/eclampsia

●Manually remove the placenta

●Remove retained products manually, with vacuum extraction, or by dilation and curettage

●Perform assisted vaginal delivery by vacuum extraction or forceps

●Perform basic neonatal resuscitation with a bag and mask

"Comprehensive" services can provide the ability to perform surgery (eg, cesarean delivery) and blood transfusions, in addition to basic services.

Access to surgical care can reduce maternal morbidity and mortality in women who require hysterectomy because of hemorrhage or who experience obstructed labor [26]. Cesarean delivery rates are an indirect measure of access to skilled providers and surgical facilities, equipment, and services. The WHO, the United Nations Children's Fund (UNICEF), and the United Nations Population Fund (UNFPA) cite a minimal cesarean delivery rate of 5 percent as evidence of adequate access to these resources [26].

Both structural and organizational barriers (eg, cost, lack of vehicles for transport, lack of telephones, difficult geographical terrain) can prolong the time it takes a woman to reach an appropriate health care facility after a problem has been recognized and the decision has been made to refer her for emergency obstetric care. Modeling techniques have predicted that a clinically important decline in maternal mortality requires access to emergency obstetric care, as well as other interventions [27]. Although intuitive, there is no high quality evidence to support this hypothesis or determine the optimal types of interventions. A systematic review of 19 studies of 14 interventions (eg, ambulances, maternity waiting homes) designed to overcome delays in receiving emergency obstetric care in LICs found that the interventions studied significantly reduced neonatal mortality and appeared to decrease stillbirths, but did not clearly demonstrate a sustained reduction in maternal mortality [28]. However, these results are difficult to interpret given the limitations of the studies, such as differences in the interventions and use of multiple interventions, differences in timing of the interventions, and lack of analysis of the effects of concurrent factors that affect maternal mortality. The authors concluded that an important goal of future research should be to understand how these interventions work and why.

Ultrasound — Availability of ultrasound examination is an essential element of emergency obstetric services in HICs and likely can play a role in reducing maternal morbidity and mortality in LICs by:

●Early identification of extrauterine pregnancy, which is an important factor for avoiding rupture and preventing ectopic pregnancy-related maternal death [29,30].

●Antepartum identification of abnormal placentation (eg, placenta previa, placenta accreta), which enables cesarean delivery under optimal conditions.

●Early identification of molar pregnancies, which may reduce the risk that the patient will develop severe hemorrhage, thyrotoxicosis, preeclampsia, or ovarian hyperstimulation syndrome.

Obstetric ultrasound is not widely available in LICs. However, the development of portable and relatively inexpensive ultrasound equipment (compact ultrasound) offers the possibility of more widespread use. Several ongoing studies have described the value and institution of ultrasound training and surveillance programs focused on emergency obstetrics and gynecology service provision [31-33]. Partners in Health has developed a free, online reference manual of ultrasound targeted for clinicians working in resource-limited settings [34].

Policies and infrastructure — Policies and infrastructure that have been identified to reduce maternal mortality include development of the following [3,35-38]:

●Services organized to ensure that antenatal care is provided through facilities and outreach programs that are available, accessible, and acceptable to all women in the service area. The infrastructure and services should reach poor disadvantaged ethnic groups and populations in rural areas with unmet health needs. Critical elements of maternal care should be available at no cost to poor patients.

●National standards and local protocols for integrated antenatal care services, management of complications, and timely referral when needed.

●Functioning referral systems (communications, ambulance).

●Integration of the provision of health care with provision of education, water, sanitation, and rural development.

●Medical and nonmedical services providing continuity of childbirth and postnatal care.

●Policies that address social, cultural, and financial factors that affect access to care and eliminate social, political, and environmental factors that adversely impact women and girls. A challenging aspect of global maternal mortality reduction is not directly related to medical services, but to eradication of poverty, inequity, gender-based violence, and exclusion of women/girls from the resources they need to develop their full human potential (eg, education) [3,39-46].

●Systems for identification of disease-specific causes of maternal mortality and near miss maternal mortality [47-50], initiation of evidence-based interventions, and monitoring of outcomes. Processes for documenting, managing, and reporting data are needed for quality improvement and improved advocacy.

In one study, continuous assessment, implementation, advocacy, outputs, and outcomes were associated with a 34 percent decrease in maternal mortality, and decreases in case fatality rates for preeclampsia (from 3.1 to 1.1 percent P<0.05) and hemorrhage (from 14.8 to 1.9 percent P<0.001) [51]. MMR decreased from 496/100,000 live births in 2007 to 328/100,000 in 2009.

MEDICAL AND OBSTETRIC DISORDERS — The leading medical and obstetric causes of maternal death in the world are hemorrhage, hypertensive disorders, and sepsis.

Peripartum hemorrhage — Hemorrhage is implicated in 25 percent of maternal deaths worldwide [52] and is consistently one of the most common causes of maternal mortality [53,54].

Approaches to prevention and treatment of hemorrhage that can be applied to both high- and low-resource settings include [55,56]:

●Active management of the third stage of labor.

●Use of protocols or guidelines for management of hemorrhage.

●Simulations or drills on management of hemorrhage for health providers.

Data from randomized trials and observational studies support the efficacy of these interventions for reducing the frequency and severity of peripartum hemorrhage, thus providing indirect evidence for a reduction in risk of maternal death due to hemorrhage. These data are reviewed separately:

●(See "Labor and delivery: Management of the normal third stage after vaginal birth", section on 'Management'.)

●(See "Management of the third stage of labor: Prophylactic pharmacotherapy to minimize hemorrhage".)

●(See "Reducing adverse obstetric outcomes through safety sciences", section on 'Postpartum hemorrhage' and "Reducing adverse obstetric outcomes through safety sciences", section on 'Peripartum hemorrhage'.)

Drugs for limiting or controlling hemorrhage after delivery include oxytocin, misoprostol, ergot alkaloids, carbetocin, and tranexamic acid (TXA) [57,58]. However, a systematic review of life-threatening pregnancy complications in low- and middle-income countries reported commonly used drugs frequently failed quality testing (test failure rates: ergometrine 75 percent, uterotonics 49 percent, oxytocin or misoprostol nearly 40 percent, injectable antibiotics 13 percent, and magnesium sulfate 3 percent) [59].

●Oxytocin – Intravenous administration of oxytocin is the major component of active management of the third stage of labor and treatment of PPH. (See "Management of the third stage of labor: Prophylactic pharmacotherapy to minimize hemorrhage", section on 'Oxytocin'.)

●Misoprostol – Misoprostol, a prostaglandin estrone (E1) analog, is an alternative to oxytocin in resource-limited settings. Although randomized trials have shown that it is less effective than oxytocin for prevention of PPH, misoprostol is more effective than no treatment, and it is inexpensive, easy to administer, and does not require refrigeration [60]. Thus, use of misoprostol is advantageous in resource-limited countries where drugs that must be refrigerated or require needles for injection/intravenous administration may pose a problem [61-69]. We agree with World Health Organization (WHO) and International Federation of Gynecology and Obstetrics (FIGO) recommendations for misoprostol use for prevention of PPH in low-resource settings [55]. It is also a reasonable approach for controlling blood loss in PPH when oxytocin or ergonovine is not available [70,71]. (See "Management of the third stage of labor: Prophylactic pharmacotherapy to minimize hemorrhage", section on 'Misoprostol'.)

●Carbetocin – Intravenous carbetocin 100 micrograms is associated with a reduced need for postpartum uterine massage after cesarean delivery (compared with oxytocin) and vaginal delivery (compared with oxytocin-ergometrine) [71]. In a study from India, compared with oxytocin, heat-stable carbetocin avoided 5468 additional postpartum hemorrhage events, 5 deaths, and 244 disability-adjusted life year conversions (DALYs) due to PPH [72]. One DALY represents the loss of the equivalent of one year of full health. (See "Management of the third stage of labor: Prophylactic pharmacotherapy to minimize hemorrhage", section on 'Carbetocin'.)

●TXA – Another option for treatment of PPH is the antifibrinolytic TXA. In the World Maternal Antifibrinolytic (WOMAN) trial, performed in 193 hospitals and 21 countries, TXA reduced maternal death by 20 to 30 percent when given within three hours of PPH diagnosis [73]. No adverse effects were demonstrated with TXA treatment. Although the agent is administered intravenously, it is not costly and does not require reconstitution or refrigeration and is, therefore, practical for use in resource-limited settings. WHO guidelines recommend the use of intravenous TXA within three hours of birth in addition to standard therapy in women with clinically diagnosed PPH [74]. (See "Management of the third stage of labor: Prophylactic pharmacotherapy to minimize hemorrhage", section on 'Tranexamic acid'.)

Additional discussions of management of PPH are presented separately.

●(See "Postpartum hemorrhage: Medical and minimally invasive management".)

●(See "Postpartum hemorrhage: Management approaches requiring laparotomy".)

Preeclampsia/eclampsia — For women with preeclampsia/eclampsia, early detection and appropriate management prior to worsening maternal status are essential elements for reducing maternal mortality. The key interventions include [75]:

●Antenatal care with periodic measurement of blood pressure. This prevents 70 percent of eclampsia by early detection of preeclampsia [76]. Lack of antenatal care is associated with increased maternal morbidity/mortality following eclampsia, independent of country of origin [77].

●Intrapartum administration of magnesium sulfate. The Magpie trial (magnesium sulphate for prevention of eclampsia) randomly assigned 10,141 preeclamptic women (85 percent from low-income countries [LIC] and middle-income countries [MIC] worldwide) to treatment with magnesium sulfate or placebo and demonstrated a 50 percent reduction of eclampsia in patients treated with magnesium sulfate [78]. Although, the Magpie trial was not statistically powered to detect differences in maternal mortality, eclampsia is a known contributor to maternal deaths globally [79]. The case fatality rates for eclampsia are as high as 3 to 5 percent in LICs and MICs, and 1 percent in high-income countries (HICs). (See "Eclampsia" and "Preeclampsia: Intrapartum and postpartum management and long-term prognosis", section on 'Seizure prophylaxis'.)

●Administration of antihypertensive therapy. Controlling severe hypertension reduces the risk of stroke [80,81]. (See "Treatment of hypertension in pregnant and postpartum patients".)

●Delivery. Delivery of the placenta always results in complete resolution of signs and symptoms of preeclampsia/eclampsia and is the only curative intervention.

Prevention — Few interventions are highly effective for preventing preeclampsia. Given the limited resources of LICs and the no more than modest impact of these interventions, we suggest available resources be applied to management rather than prevention of preeclampsia.

In randomized trials of women at moderate to high risk of developing the disorder, low dose aspirin had a modest impact in reducing the risk of preeclampsia, as well as other adverse pregnancy outcomes (eg, preterm delivery, fetal growth restriction). These data are reviewed separately. (See "Preeclampsia: Prevention", section on 'Low-dose aspirin'.)

Data from a 2014 meta-analysis of randomized trials also show that calcium supplementation during pregnancy significantly reduced the risk of developing preeclampsia, especially in women at high risk of developing the disease (five trials, 587 women: risk ratio [RR] 0.22, 95% CI 0.12-0.42) or low baseline calcium intake (eight trials, 10,678 women: RR 0.36, 95% CI 0.20-0.65) [82]. Maternal mortality was also reduced, but the number of deaths was small (n = 7) and the reduction did not reach statistical significance (RR 0.17, 95% CI 0.02-1.39).

Infection — Most cases of life-threatening pregnancy-related infection in LICs and MICs are due to puerperal sepsis (eg, chorioamnionitis, endometritis), pyelonephritis/urosepsis, septic abortion, or skin and soft tissue infection (eg, necrotizing fasciitis, abscess, cellulitis, myonecrosis) [83].

Bacterial infection — Problems related to infection control in resource-limited countries include poor antibiotic prescribing practices, poorly functioning laboratory services, lack of surveillance data, suboptimal design or construction of buildings and water and sanitation systems, overcrowding of facilities, insufficient numbers of trained health workers, and insufficient understanding of basic infection control issues [84].

Sepsis is responsible for 2 percent of maternal deaths in the United States and other HICs, but results in 10 to 12 percent of deaths in LICs and MICs [85]. Most of these deaths are due to postpartum bacterial infection, which can be reduced by timely use of antibiotics according to established protocols.

The concept that puerperal sepsis can be prevented by improved hygiene dates back to Ignaz Semmelweiss (1818-1865) and Oliver Wendell Holmes (1809-1894). In order to reduce the risk of puerperal bacterial infection in low-resource areas, WHO promotes the observance of "six cleans" at the time of delivery: clean hands, clean perineum, clean delivery surface, clean cord and tying instruments, and clean cutting surfaces [86]. This is best achieved through use of clean delivery kits, which are associated with a reduction in maternal and neonatal sepsis [87-89]. Most kits contain a small bar of soap for washing hands, a plastic sheet to use as the delivery surface, clean gloves, clean string for tying the umbilical cord, a new razor blade or scalpel for cutting the cord, and pictorial instructions that illustrate the sequence of delivery events and hand-washing.

Viruses and parasites — Viruses and parasites also contribute to infection-related maternal death. Influenza-associated mortality appears to be higher in pregnant women than in nonpregnant women. Data from observational studies suggest that public health measures, such as vaccination and use of antiviral drugs, reduce this risk. These data are reviewed in detail separately. (See "Seasonal influenza and pregnancy".)

HIV — While maternal mortalities related to the human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) are now rare in HICs where access to appropriate therapies is available, HIV/AIDs contributes to the high maternal mortality rates in Sub-Saharan Africa [90,91]. Maternal HIV/AIDS is associated with an increased risk of maternal death from endometritis, pneumonia, tuberculosis, and malaria [92]. (See "Prenatal evaluation of women with HIV in resource-rich settings" and "Antiretroviral selection and management in pregnant individuals with HIV in resource-rich settings" and "Prevention of HIV transmission during breastfeeding in resource-limited settings".)

HPV — Human papillomavirus (HPV) infection contributes to cervical cancer, which is one of the most common malignancies globally and in resource-limited settings.

●(See "Human papillomavirus infections: Epidemiology and disease associations".)

●(See "Screening for cervical cancer in resource-limited settings".)

Malaria — Malaria is a major cause of maternal death in endemic areas, even in the absence of HIV infection. Prevention involves chemoprophylaxis and mosquito avoidance; treatment consists of antimalarial therapy and supportive care. (See "Malaria in pregnancy: Epidemiology, clinical manifestations, diagnosis, and outcome" and "Malaria in pregnancy: Prevention and treatment".)

WORLD HEALTH ORGANIZATION RECOMMENDATIONS — The World Health Organization (WHO) provides written descriptions of the key effective interventions for maternity and newborn care for use by communities and/or facilities in resource-limited countries [93-95]. These recommendations include access to:

●Family planning services.

●Safe abortion services.

●Emergency obstetric care (EMOC).

●Essential preventive and promotive care in pregnancy, including prevention of mother to child transmission of human immunodeficiency virus (HIV), and the following:

•Nationally agreed standards and local protocols for integrated antenatal care services and timely referral and management of complications.

•Policies that address social, cultural, and financial factors that affect access to care.

•Services organized to ensure that antenatal care is provided through facilities and outreach programs that are available, accessible and acceptable to all women in the service area.

•Services linked to a health care system providing continuity with childbirth and postnatal care.

•Skilled health professionals.

•Essential medicines and medical devices.

•Functioning referral system (communications, ambulance).

•Adequate recording and reporting systems.

•Use of data for quality improvement.

EXAMPLES OF SUCCESSFUL INTERVENTION — Malaysia and Sri Lanka reduced their very high maternal mortality ratio (MMR) over a period of four decades, despite low per capita incomes (half of the population is below the poverty line) and high illiteracy rates for women when these programs were initiated. Malaysia reduced MMR from 534/100,000 live births in 1950 to 18/100,000 live births in 1991; Sri Lanka reduced MMR from 1056/100,000 live births in 1947 to 27/100,000 live births in 1992 [96].

Lessons reinforced by both countries included:

●Impact of rheumatic valve disease – Cardiac disease is a major cause of maternal mortality in Sri Lanka, second only to postpartum hemorrhage [97]. Rheumatic mitral valve disease is responsible for more than one-third of maternal deaths from cardiac disease. Substandard care was identified in all cases; strategies to improve care had to allow a reduction in maternal cardiac deaths.

These reductions were achieved with relatively low expenditures on maternal health: 0.2 to 0.3 percent of the gross domestic product. Review of the amount of time it took these countries to halve their MMR suggests that, once a country reaches a MMR of 200/100,000 live births, it can further halve maternal mortality in 7 to 10 years.

●Need for family planning services – Lack of access to safe abortion has been identified as a contributor to maternal mortality for those at risk for death from rheumatic heart disease. Strengthening family planning education is probably the most important intervention since almost 50 percent of maternal deaths in Sri Lanka have been reported to be due to an unmet need for contraception/safe abortion in one way or another. Review of abortion restrictions for women with preexisting heart disease might lead to improvement in maternal mortality for this leading cause in Sri Lanka [98].

The global gag rule imposed by the previous administration in the United States in January 2017 impacted 32 countries and 53 health care projects worldwide and turned back the human rights of women and girls around the world [99,100]. Denying access to abortion did not stop women and girls from seeking abortion services. Rather, it made the procedure less safe and contributed to maternal mortality. This policy was rescinded in January 2021.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General prenatal care".)

SUMMARY AND RECOMMENDATIONS

●Causes of maternal mortality – The leading causes of maternal mortality in pregnant women are hemorrhage, hypertensive disorders, infection, obstructed labor, and complications from unsafe abortions. (See 'Introduction' above.)

●Strategies to reduce maternal mortality

•Access to family planning – Availability of free, accessible family planning appears to be a key factor in reducing maternal mortality. Reduction in unwanted pregnancy reduces pregnancy-related mortality and abortion-related mortality. (See 'Family planning' above.)

•Skilled birth attendants and emergency care – The availability of skilled birth attendants and resources for emergency obstetric care are major goals for reducing intrapartum and postpartum mortality. (See 'Skilled birth attendants' above and 'Emergency obstetric care' above.)

•Prevention of postpartum hemorrhage – For prevention of postpartum hemorrhage (PPH), misoprostol is less effective than oxytocin, but more effective than no treatment. However, it is a reasonable option in resource-poor countries where drugs that must be refrigerated or require needles for injection/intravenous administration may pose a problem. It is also a reasonable approach for controlling blood loss in PPH when oxytocin or ergonovine is not available. In resource-limited countries, carbetocin has been shown to be most effective in prevention as the quality of oxytocin and misoprostol has been called into question. (See 'Peripartum hemorrhage' above.)

•Detection of preeclampsia – Antenatal care with periodic measurement of blood pressure potentially prevents 70 percent of eclampsia by early detection of preeclampsia. Case fatality rates for eclampsia are as high as 3 to 5 percent in low-income countries (LICs). Additional key interventions for reduction of maternal morbidity and mortality include administration of magnesium sulfate and antihypertensive therapy of severe hypertension. (See 'Preeclampsia/eclampsia' above.)

●Benefit of "six cleans" – We agree with World Health Organization (WHO) recommendations for observance of "six cleans" at the time of delivery: clean hands, clean perineum, clean delivery surface, clean cord and tying instruments, and clean cutting surfaces (Grade 1B). Use of a clean delivery kit reduces maternal and neonatal sepsis. (See 'Bacterial infection' above.)