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Approaches to reduction of maternal mortality in resource-limited settings

Approaches to reduction of maternal mortality in resource-limited settings
Literature review current through: Jan 2024.
This topic last updated: Jun 12, 2023.

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 'Active 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.)

  1. United Nations. We can end poverty: Millennium development goals and beyond 2015. http://www.un.org/millenniumgoals/bkgd.shtml (Accessed on July 16, 2012).
  2. Bhutta ZA, Chopra M, Axelson H, et al. Countdown to 2015 decade report (2000-10): taking stock of maternal, newborn, and child survival. Lancet 2010; 375:2032.
  3. United Nations Sustainable Development Goals http://www.un.org/sustainabledevelopment/sustainable-development-goals/ (Accessed on April 15, 2016).
  4. Campbell OM, Graham WJ, Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works. Lancet 2006; 368:1284.
  5. Tita AT, Stringer JS, Goldenberg RL, Rouse DJ. Two decades of the safe motherhood initiative: time for another wooden spoon award? Obstet Gynecol 2007; 110:972.
  6. Ronsmans C, Graham WJ, Lancet Maternal Survival Series steering group. Maternal mortality: who, when, where, and why. Lancet 2006; 368:1189.
  7. Carvalho N, Salehi AS, Goldie SJ. National and sub-national analysis of the health benefits and cost-effectiveness of strategies to reduce maternal mortality in Afghanistan. Health Policy Plan 2013; 28:62.
  8. Rah JH, Christian P, Shamim AA, et al. Pregnancy and lactation hinder growth and nutritional status of adolescent girls in rural Bangladesh. J Nutr 2008; 138:1505.
  9. Shirima CP, Kinabo JL. Nutritional status and birth outcomes of adolescent pregnant girls in Morogoro, Coast, and Dar es Salaam regions, Tanzania. Nutrition 2005; 21:32.
  10. Ahmed S, Li Q, Liu L, Tsui AO. Maternal deaths averted by contraceptive use: an analysis of 172 countries. Lancet 2012; 380:111.
  11. Guttmacher Institute. Abortion Worldwide: A decade of uneven progress. http://www.guttmacher.org/pubs/Abortion-Worldwide.pdf (Accessed on July 12, 2012).
  12. Singh K, Ratnam SS. The influence of abortion legislation on maternal mortality. Int J Gynaecol Obstet 1998; 63 Suppl 1:S123.
  13. Conde-Agudelo A, Belizán JM. Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study. BMJ 2000; 321:1255.
  14. Conde-Agudelo A, Rosas-Bermúdez A, Kafury-Goeta AC. Effects of birth spacing on maternal health: a systematic review. Am J Obstet Gynecol 2007; 196:297.
  15. Grahm WJ, Bell J, Bullough C. Can skilled attendance at delivery reduce maternal mortality in developing countries? In: Safe Motherhood Strategies: A Review of the Evidence, De Brouwere V, van Lerberghe W (Eds), ITG Press, Antwerp 2001. p.97.
  16. WHO, ICM, and FIGO. Making pregnancy safer: The critical role of the skilled attendant. WHO, Geneva 2004.
  17. Byrne A, Morgan A. How the integration of traditional birth attendants with formal health systems can increase skilled birth attendance. Int J Gynaecol Obstet 2011; 115:127.
  18. Fauveau V, Stewart K, Khan SA, Chakraborty J. Effect on mortality of community-based maternity-care programme in rural Bangladesh. Lancet 1991; 338:1183.
  19. Wilson A, Gallos ID, Plana N, et al. Effectiveness of strategies incorporating training and support of traditional birth attendants on perinatal and maternal mortality: meta-analysis. BMJ 2011; 343:d7102.
  20. Homer CS, Friberg IK, Dias MA, et al. The projected effect of scaling up midwifery. Lancet 2014; 384:1146.
  21. Liu L, Johnson HL, Cousens S, et al. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet 2012; 379:2151.
  22. WHO, UNICEF, UN Population Fund and the World Bank. Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank estimates. Geneva: World Health Organization, 2012.
  23. Doctor HV, Findley SE, Ager A, et al. Using community-based research to shape the design and delivery of maternal health services in Northern Nigeria. Reprod Health Matters 2012; 20:104.
  24. Oyerinde K, Harding Y, Amara P, et al. A qualitative evaluation of the choice of traditional birth attendants for maternity care in 2008 Sierra Leone: implications for universal skilled attendance at delivery. Matern Child Health J 2013; 17:862.
  25. World Health Organization. Monitoring obstetric care: A handbook. whqlibdoc.who.int/publications/2009/9789241547734_eng.pdf (Accessed on July 18, 2012).
  26. AbouZahr C, Wardlaw T. Maternal mortality at the end of a decade: signs of progress? Bull World Health Organ 2001; 79:561.
  27. Goldie SJ, Sweet S, Carvalho N, et al. Alternative strategies to reduce maternal mortality in India: a cost-effectiveness analysis. PLoS Med 2010; 7:e1000264.
  28. Hussein J, Kanguru L, Astin M, Munjanja S. The effectiveness of emergency obstetric referral interventions in developing country settings: a systematic review. PLoS Med 2012; 9:e1001264.
  29. Sy T, Diallo Y, Toure A, et al. [Management of ectopic pregnancy in Conakry, Guinea]. Med Trop (Mars) 2009; 69:565.
  30. Nayama M, Gallais A, Ousmane N, et al. [Management of ectopic pregnancy in developing countries: example of a Nigerian reference maternity]. Gynecol Obstet Fertil 2006; 34:14.
  31. Shah SP, Epino H, Bukhman G, et al. Impact of the introduction of ultrasound services in a limited resource setting: rural Rwanda 2008. BMC Int Health Hum Rights 2009; 9:4.
  32. Harris RD, Marks WM. Compact ultrasound for improving maternal and perinatal care in low-resource settings: review of the potential benefits, implementation challenges, and public health issues. J Ultrasound Med 2009; 28:1067.
  33. Kimberly HH, Murray A, Mennicke M, et al. Focused maternal ultrasound by midwives in rural Zambia. Ultrasound Med Biol 2010; 36:1267.
  34. Shah S, Price. Manual of Ultrasound for Resource—Limited Settings 2011. Partners in Health. http://www.pih.org/publications/entry/manual-of-ultrasound-for-resource-limited-settings (Accessed on June 22, 2012).
  35. Pathmanathan I, Liljestrand J, Martins JM. Investing in maternal health. Learning from Malaysia and Sri Lanka. World Bank, Washington, DC 2003.
  36. Koblinsky M ed. Reducing maternal morality: learning from Bolivia, China, Egypt, Honduras, Indonesia, Jamaica, and Zimbabwe. World Bank, Washington DC 2003.
  37. Packages of Interventions for Family Planning, Safe Abortion care, Maternal, Newborn and Child Health. http://whqlibdoc.who.int/hq/2010/WHO_FCH_10.06_eng.pdf (Accessed on March 22, 2011).
  38. WHO Technical consultation on postpartum and postnatal care. http://www.who.int/making_pregnancy_safer/documents/WHO_MPS_10_03/en/index.html (Accessed on March 22, 2011).
  39. Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375:1609.
  40. Amowitz LL, Kim G, Reis C, et al. Human rights abuses and concerns about women's health and human rights in southern Iraq. JAMA 2004; 291:1471.
  41. Amowitz LL, Reis C, Iacopino V. Maternal mortality in Herat Province, Afghanistan, in 2002: an indicator of women's human rights. JAMA 2002; 288:1284.
  42. Swiss S, Jennings PJ, Aryee GV, et al. Violence against women during the Liberian civil conflict. JAMA 1998; 279:625.
  43. Nour NN. Maternal health considerations during disaster relief. Rev Obstet Gynecol 2011; 4:22.
  44. Amowitz LL, Reis C, Lyons KH, et al. Prevalence of war-related sexual violence and other human rights abuses among internally displaced persons in Sierra Leone. JAMA 2002; 287:513.
  45. Mukherjee JS, Barry DJ, Satti H, et al. Structural violence: a barrier to achieving the millennium development goals for women. J Womens Health (Larchmt) 2011; 20:593.
  46. Cook RJ, Dickens BM. Human rights to safe motherhood. Int J Gynaecol Obstet 2002; 76:225.
  47. Say L, Pattinson RC, Gülmezoglu AM. WHO systematic review of maternal morbidity and mortality: the prevalence of severe acute maternal morbidity (near miss). Reprod Health 2004; 1:3.
  48. Filippi V, Brugha R, Browne E, et al. Obstetric audit in resource-poor settings: lessons from a multi-country project auditing 'near miss' obstetrical emergencies. Health Policy Plan 2004; 19:57.
  49. Filippi V, Ganaba R, Baggaley RF, et al. Health of women after severe obstetric complications in Burkina Faso: a longitudinal study. Lancet 2007; 370:1329.
  50. Weeks A, Lavender T, Nazziwa E, Mirembe F. Personal accounts of 'near-miss' maternal mortalities in Kampala, Uganda. BJOG 2005; 112:1302.
  51. Srofenyoh E, Ivester T, Engmann C, et al. Advancing obstetric and neonatal care in a regional hospital in Ghana via continuous quality improvement. Int J Gynaecol Obstet 2012; 116:17.
  52. Bayer A. Population Resource Center. January 2001 www.prcdc.org/files/Maternal_Mortality.pdf (Accessed on July 18, 2012).
  53. Cristina Rossi A, Mullin P. The etiology of maternal mortality in developed countries: a systematic review of literature. Arch Gynecol Obstet 2012; 285:1499.
  54. Coyaji BJ. Maternal mortality and morbidity in the developing countries like India. Indian J Matern Child Health 1991; 2:3.
  55. WHO, ICM, FIGO. Making pregnancy safer: the critical role of the skilled attendant. Geneva: WHO, 2004.
  56. Chang OH, Levy B, Lytle H, et al. Implementation of the Alliance for Innovation on Maternal Health Program to Reduce Maternal Mortality in Malawi. Obstet Gynecol 2019; 133:507.
  57. WHO recommendations: Uterotonics for the prevention of postpartum haemorrhage. World Health Organization 2018. Available at: https://apps.who.int/iris/bitstream/handle/10665/277276/9789241550420-eng.pdf (Accessed on June 08, 2023).
  58. Gallos ID, Papadopoulou A, Man R, et al. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Cochrane Database Syst Rev 2018; 12:CD011689.
  59. Torloni MR, Bonet M, Betrán AP, et al. Quality of medicines for life-threatening pregnancy complications in low- and middle-income countries: A systematic review. PLoS One 2020; 15:e0236060.
  60. Tunçalp Ö, Hofmeyr GJ, Gülmezoglu AM. Prostaglandins for preventing postpartum haemorrhage. Cochrane Database Syst Rev 2012; :CD000494.
  61. Pagel C, Lewycka S, Colbourn T, et al. Estimation of potential effects of improved community-based drug provision, to augment health-facility strengthening, on maternal mortality due to post-partum haemorrhage and sepsis in sub-Saharan Africa: an equity-effectiveness model. Lancet 2009; 374:1441.
  62. Tsu VD, Langer A, Aldrich T. Postpartum hemorrhage in developing countries: is the public health community using the right tools? Int J Gynaecol Obstet 2004; 85 Suppl 1:S42.
  63. Lokugamage AU, Sullivan KR, Niculescu I, et al. A randomized study comparing rectally administered misoprostol versus Syntometrine combined with an oxytocin infusion for the cessation of primary post partum hemorrhage. Acta Obstet Gynecol Scand 2001; 80:835.
  64. Calişkan E, Meydanli MM, Dilbaz B, et al. Is rectal misoprostol really effective in the treatment of third stage of labor? A randomized controlled trial. Am J Obstet Gynecol 2002; 187:1038.
  65. Høj L, Cardoso P, Nielsen BB, et al. Effect of sublingual misoprostol on severe postpartum haemorrhage in a primary health centre in Guinea-Bissau: randomised double blind clinical trial. BMJ 2005; 331:723.
  66. Enakpene CA, Morhason-Bello IO, Enakpene EO, et al. Oral misoprostol for the prevention of primary post-partum hemorrhage during third stage of labor. J Obstet Gynaecol Res 2007; 33:810.
  67. Parsons SM, Walley RL, Crane JM, et al. Rectal misoprostol versus oxytocin in the management of the third stage of labour. J Obstet Gynaecol Can 2007; 29:711.
  68. Derman RJ, Kodkany BS, Goudar SS, et al. Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities: a randomised controlled trial. Lancet 2006; 368:1248.
  69. Mobeen N, Durocher J, Zuberi N, et al. Administration of misoprostol by trained traditional birth attendants to prevent postpartum haemorrhage in homebirths in Pakistan: a randomised placebo-controlled trial. BJOG 2011; 118:353.
  70. Mousa HA, Blum J, Abou El Senoun G, et al. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev 2014; :CD003249.
  71. Su LL, Chong YS, Samuel M. Carbetocin for preventing postpartum haemorrhage. Cochrane Database Syst Rev 2012; :CD005457.
  72. Cook JR, Saxena K, Taylor C, Jacobs JL. Cost-effectiveness and budget impact of heat-stable carbetocin compared to oxytocin and misoprostol for the prevention of postpartum hemorrhage (PPH) in women giving birth in India. BMC Health Serv Res 2023; 23:267.
  73. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 2017; 389:2105.
  74. World Health Organization. WHO recommendation on tranexamic acid for the treatment of postpartum hemorrhage. Geneva 2017.
  75. Goldenberg RL, McClure EM, Macguire ER, et al. Lessons for low-income regions following the reduction in hypertension-related maternal mortality in high-income countries. Int J Gynaecol Obstet 2011; 113:91.
  76. Carroli G, Rooney C, Villar J. How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence. Paediatr Perinat Epidemiol 2001; 15 Suppl 1:1.
  77. MacKay AP, Berg CJ, Atrash HK. Pregnancy-related mortality from preeclampsia and eclampsia. Obstet Gynecol 2001; 97:533.
  78. Altman D, Carroli G, Duley L, et al. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet 2002; 359:1877.
  79. Duley L. The global impact of pre-eclampsia and eclampsia. Semin Perinatol 2009; 33:130.
  80. Working group report on high blood pressure in pregnancy. National Institutes of Health, Washington, DC 2000.
  81. Martin JN Jr, Thigpen BD, Moore RC, et al. Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol 2005; 105:246.
  82. Hofmeyr GJ, Lawrie TA, Atallah AN, et al. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev 2014; :CD001059.
  83. Gravett CA, Gravett MG, Martin ET, et al. Serious and life-threatening pregnancy-related infections: opportunities to reduce the global burden. PLoS Med 2012; 9:e1001324.
  84. Hussein J, Mavalankar DV, Sharma S, D'Ambruoso L. A review of health system infection control measures in developing countries: what can be learned to reduce maternal mortality. Global Health 2011; 7:14.
  85. Khan KS, Wojdyla D, Say L, et al. WHO analysis of causes of maternal death: a systematic review. Lancet 2006; 367:1066.
  86. World Health Organization. Essential newborn care: report of a technical working group. 1994 http://helid.digicollection.org/es/d/Js2892e/ (Accessed on July 18, 2012).
  87. Darmstadt GL, Hassan M, Balsara ZP, et al. Impact of clean delivery-kit use on newborn umbilical cord and maternal puerperal infections in Egypt. J Health Popul Nutr 2009; 27:746.
  88. Winani S, Wood S, Coffey P, et al. Use of a clean delivery kit and factors associated with cord infection and puerperal sepsis in Mwanza, Tanzania. J Midwifery Womens Health 2007; 52:37.
  89. Mosha F, Winani S, Wood S, et al. Evaluation of the effectiveness of a clean delivery kit intervention in preventing cord infection and puerperal sepsis among neonates and their mothers in rural Mwanza Region, Tanzania. Tanzan Health Res Bull 2005; 7:185.
  90. Le Coeur S, Khlat M, Halembokaka G, et al. HIV and the magnitude of pregnancy-related mortality in Pointe Noire, Congo. AIDS 2005; 19:69.
  91. Bicego G, Boerma JT, Ronsmans C. The effect of AIDS on maternal mortality in Malawi and Zimbabwe. AIDS 2002; 16:1078.
  92. van den Akker T, de Vroome S, Mwagomba B, et al. Peripartum infections and associated maternal mortality in rural Malawi. Obstet Gynecol 2011; 118:266.
  93. Packages of Interventions for Family Planning, Safe Abortion care, Maternal, Newborn and Child Health. http://whqlibdoc.who.int/hq/2010/WHO_FCH_10.06_eng.pdf (Accessed on June 22, 2012).
  94. WHO Technical consultation on postpartum and postnatal care. http://www.who.int/making_pregnancy_safer/documents/WHO_MPS_10_03/en/index.html (Accessed on June 22, 2012).
  95. World Health Organization. Monitoring Emergency Obstetric Care: a handbook. 2009. http://www.unfpa.org/public/publications/pid/3073 (Accessed on July 19, 2012).
  96. Sri Lanka Department of Census and Statistics and Malaysia Department of Statistics
  97. Haththotuwa HR, Attygalle D, Jayatilleka AC, et al. Maternal mortality due to cardiac disease in Sri Lanka. Int J Gynaecol Obstet 2009; 104:194.
  98. Weerasekera D. Presidential address – 2017. S L J Obstet Gynaecol 2017; 39:1.
  99. Mavodza C, Goldman R, Cooper B. The impacts of the global gag rule on global health: a scoping review. Glob Health Res Policy 2019; 4:26.
  100. Planned Parenthood. What Is the Global Gag Rule? https://www.plannedparenthoodaction.org/communities/planned-parenthood-global/end-global-gag-rule (Accessed on February 16, 2021).
Topic 16688 Version 29.0

References

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