EGH interview: Reducing fertility and improving access to quality care sure steps to reducing maternal mortality

Since 2000, as a region, South Asia - and particularly Bangladesh, India and Nepal - have lowered their maternal mortality rate significantly.

In advance of the publication of new Exemplars in Global Health research that examines why countries like Bangladesh are outpacing their neighbors in reducing neonatal mortality rates and maternal mortality (NMR/MMR), we spoke with the EGH NMR/MMR Lead, Dr. Gloria Ikilezi.

Dr. Ikilezi said the research will show that reducing fertility, improving access to quality care, and strong integration of the public and private sectors are all important factors in addressing reproductive and maternal health.

Why did Exemplars in Global Health choose NMR/MMR as an area of research?

Dr. Ikilezi: Reducing maternal and child mortality is a major global health priority with multiple ongoing efforts to end preventable causes of death over the next decade. The NMR/MMR research was therefore born out of demand from different key stakeholders including the Gates Foundation. This project succeeded one of the EGH flagship research topics, under-five mortality, which looked at the drivers of mortality reduction among children. Neonatal mortality contributes a significant portion of this burden accounting for over 40 percent of total childhood deaths. This prompted us to take a closer look at the drivers of mortality reduction in the neonate sub-population, and given the critical linkage to maternal factors, we kicked off the NMR / MMR research in early 2020.

Bangladesh is a notably positive outlier in NMR/MMR. Why is that?

Dr. Ikilezi: Bangladesh is one of the lower middle-income countries in South Asia that has made outstanding progress in addressing maternal and neonatal mortality since 2000. Estimates of maternal mortality show a reduction of 5.4 percent per year from 434 deaths per 100,000 live births in 2000, to 173 in 2017. Neonatal mortality decreased by five percent per year from 42 deaths per 1000 in 2000, to 18 in 2020. A previous case study led by Countdown 2030 also showed that Bangladesh was among the few LMICs on track to achieve the primary target of Millennium Development Goal 5 [to reduce maternal mortality by 75 percent and achieve universal access to reproductive health] by 2015. Relatedly, Bangladesh is a data-rich country, thanks to its efforts to implement key population surveys and vital registration systems in a consistent manner. Some of Bangladesh's key strategies include fertility reduction, improved access to quality care, and strong integration of the public and private sector in addressing reproductive and maternal health.

Sustainable Development Goal target 3.1 calls for a reduction in global MMR to less than 70 per 100,000 live births by 2030. It also says no country should have an MMR greater than 140 per 100,000 live births. How is Bangladesh faring against this goal and how does its performance compare to its neighbors?

Dr. Ikilezi: Per UN estimates, MMR in Bangladesh declined by about seven percent annually over the last decade, which positions the country for success regarding the SDG target. If the current rate of decline is maintained, we estimate MMR will decline to about 68 per 100,000 live births in 2030, using the 2017 estimates as baseline. This will require continued efforts to sustain, or better still accelerate progress with a targeted focus on geographic divisions that have been shown to experience lagged progress. Overall, maternal mortality in South Asia has declined significantly since 2000, however, country level variations remain in both absolute and relative terms. India and Nepal are some of the neighboring countries that have achieved higher annual reductions than the regional average, at 5.7 and 6.2 percent respectively, between 2000 and 2017.

Most maternal deaths are preventable. Why have we been unable to prevent them, particularly in LMICs?

Dr. Ikilezi: Maternal factors, especially in low-income settings are a major cause of death and yet the bulk of the complications or risk factors are largely preventable. The main drivers of death in these settings include hemorrhage, infections, and hypertensive disease. We know that ensuring timely diagnosis and accurate management of mothers presenting with these conditions would substantially avert the mortality picture. Unfortunately, this remains a far cry for both mothers and health care workers in some settings. In fact, literature shows that less than 50 percent of all births in LMICs are assisted by a skilled birth attendant (SBA). Despite existing policies and strategies aimed to increase institutional births, notable disparities remain, with SBA coverage as low as 30 percent in some countries in sub-Saharan Africa. A considerable proportion of mothers continue to experience birth outside a health facility due to structural barriers to access or even long-standing traditional norms that influence care seeking practices. Continued efforts are therefore needed to ensure every mother has access to skilled birth attendance, including emergency care wherever they are, to ensure safe and effective management.

What is the role of non-communicable diseases in NMR/MMR?

Dr. Ikilezi: Non-communicable diseases (NCDs) such as diabetes and hypertension, and other cardiovascular conditions are an important driver of neonatal and maternal deaths. NCDs may be pregnancy-induced or from existing health problems prior to the pregnancy. In more developed settings, the bulk of maternal mortality is driven by complications arising from such conditions, commonly referred to as indirect causes of death. When these go undetected, or if mismanaged due to poor access and lack of specialized care, complications of pregnancy and labor are exacerbated, potentially leading to death. A holistic approach to care through integration of maternal and neonatal health services including management of co-morbidities would significantly improve mortality outcomes.

On International Women’s Day we heard arguments that family planning and access to contraception should be considered a human right. How does access to contraception help prevent NMR and MMR?

Dr. Ikilezi: Increased awareness of family planning and access to contraception is a critical step in reducing NMR/MMR. This is particularly important among high-risk populations such as adolescent girls, through reducing deaths that occur as a result of complicated deliveries as well as unsafe abortions. With increased access, the risk of poor outcomes among women with other high-risk attributes outside of age, such as high parity or narrow birth intervals, also decreases.

What is your hope for how this research on Bangladesh will impact policymakers, implementers, and others around the world?

Dr. Ikilezi: To meet current global maternal and child health targets amidst the ongoing recovery from the COVID-19 pandemic, most countries in the LMIC context will require accelerated progress. Our research highlights success stories from diverse contexts, including different innovations that countries have applied to make global guidelines or strategies work well in their contexts. My hope is that end users will find utility in the lessons shared and that the Exemplars work overall can provide a sense of renewed inspiration as they work towards positive change in their settings.