This meeting was convened in Ho Chi Minh City by Dr Nariman Awin, the WHO Regional Advisor for Making Pregnancy Safer, and I was fortunate to attend as an official observer for the MWIA. The Regional Reproductive Health Strategy was endorsed at the WPRO/SEARO joint meeting on reducing maternal mortality in Manila in 2003. This meeting allowed countries to report on their five year progress and compare successes and failures in strategies to reduce MMR. The seven priority countries represented at the meeting were Cambodia, China, Laos PDR, Mongolia, Papua New Guinea, The Philippines and Viet Nam.
After the official welcome the meeting began with country reports.
In Cambodia whilst there has been steady progress on key child health indicators, efforts to decrease the maternal mortality rate (MMR) are yet to show results, with a national MMR of 450 per 100 000 live-births unchanged from 2000 to 2005. Reduction in MMR has been hindered by poor access to health facilities, low levels of female education and financial barriers of the cost of pregnancy care and transport. There is also a shortage of midwives with 74 health centres out of 957 having no skilled health personnel who can conduct births. Like many of the priority countries, access to health care for the poor is a particular challenge and the Ministry of Planning in Cambodia has introduced an identification card to enable free access to pregnancy related health care to try and redress this.
The situation in Laos PDR also remains critical, with 3 women dying every day from childbirth and a lifetime risk of death from childbirth of 1 in 25. Antenatal coverage is low, with only 29% of women accessing any antenatal care. Worryingly the National Assessment of Skilled Birth Attendance survey (2007) showed very low levels of knowledge of essential obstetric care amongst providers, notably 0% of workers at community health centres being aware of active management of the third stage of labour. The Lao PDR Ministry of Health has recognised the urgency of this situation and has developed the National Skilled Birth Attendant Plan which consists of three main strategies: establishing a skilled work force, ensuring education and training programs are in place to up skill existing health workers and development of a system to monitor and manage training of birth attendants. The short-term goal of the national plan is to ensure that there is one (ideally two) health care workers who have emergency obstetric skills training in every facility. The long-term goal is to train specialist midwives with high-level skills and also general midwives with medium level skills. The challenges are immense and maintaining sustained political commitment, coordination of the program and ensuring quality of training being identified were identified as potential barriers.
Probably the country with the most critical situation was Papua New Guinea, where the MMR is the highest in the WPR at 733 per 100 000 live births. The generation of this figure was debated, as the 10 yearly Department of health survey (DHS) covers a representative sample of 10 000 people out of a population of approximately 6 million and compared to the previous estimate this number seems to have almost doubled. Given the poverty and remoteness of most of the population the current figure is however unlikely to be an underestimate. Like in the Lao PDR lack of access to antenatal care and poor quality of care particularly in the highlands is a major problem. There is a shortage of obstetric care throughout the country with 9 of 19 District Hospitals having no trained obstetric and gynaecological medical personnel. The fertility rate remains high at 4.4 and access to family planning is a priority. The lack of any drugs or medical equipment is a problem in many health posts, and there was debate about the value of misoprostol for management of post partum haemorrhage in remote situations in tropical countries like PNG in settings without refrigeration and electricity. Maternity waiting homes have been built as pilot projects and seem to be successful, although commitment to nationwide rollout has yet to happen.
More encouraging reports came from China, Mongolia and Vietnam where good progress seems to be being made towards reducing overall maternal mortality. However the issue of gross differences in progress between urban and rural populations as well as the particular situation of the ethnic minority groups living in remote and often mountainous regions was acknowledged and these pose a great challenge to these countries. In Vietnam for example the MMR in Ha Tay, an urban area, has fallen to 46 per 100 000 live births yet in the mountainous region of Cao Bang the maternal death rate is 411 per 100 000 live births.
In the Philippines steady progress is being made in reducing the MMR, largely through trying to increase the rate of skilled attendance at deliveries and facility deliveries (currently 38%). Reasons why women prefer Hilots (traditional birth attendants-TBA) to care for them during childbirth at home were presented, including greater privacy, less cost, ability to have family members around and the ability to be able to continue caring for other children. In response to this the Philippines have tried to incorporate TBAs into mainstream care by giving them financial incentives to encourage women to have a facility based birth and offering educational assistance for those who wish to up skill. The TBAs are being trained to help monitor maternal outcomes in and out of facility settings.
What became clear from all the country reports is that success or failure to achievement of MDG5 depends on development progress in many areas outside the health sector including transport, education and gender equality.
The major focus of the second day of the meeting was understanding the source of the numbers and to develop strategies to improve the capture rate of maternal deaths in countries without vital registration. This day led by Dr Jelka Zupan from WHO headquarters in Geneva, also included debate on the monitoring and uptake of antenatal care. This is particularly important given that in several of the priority countries despite improved rates of antenatal care and facility births, maternal mortality levels remain unacceptably high.
The most recent WHO/UNFPA/UNICEF/World Bank report “Maternal Mortality Estimates 2005” highlights the lack of reliable data from Cambodia, the Lao PDR, The Philippines, Vietnam and PNG. Estimates from these countries are from DHS surveys utilising direct and indirect sisterhood methods of approximating maternal mortality. China measures maternal mortality using a system based upon sample vital registration. Strategies to combine data from different sources were discussed and individual country plans made to increase the accuracy of recording maternal deaths as well as proportion of SBA. Abortion related deaths, a major contributing factor to maternal mortality, are seldom recorded and owing to the sensitive nature of this area it is unlikely that country specific data will ever be published.
The definition of Skilled Birth Attendant (SBA) was discussed, and it soon became apparent that some countries were not using the WHO/FIGO/ICM consensus definition and rather equated facility delivery with delivery by a SBA, a proxy measure that may not reflect the actual ‘skill’ a woman received during delivery.
When individual countries representatives were asked for ideas to put to their ministries of health on how to improve the recording of maternal deaths and SBA utilisation, some innovative policy ideas emerged and hopefully at the next meeting some improvement will have been seen. In PNG for example it was proposed to utilise an existing radio network in each of the remote health clinics to record the number of deaths of pregnant women (direct and indirect) in each village setting on a monthly basis which hopefully can also capture deaths outside health facilities. Laos PDR hopes to introduce a maternal and perinatal death reporting system at village level and proposed the use of proxy markers such as use of oxytocin; antenatal clinic visits and post natal checks to measure SBA utilisation. Vietnam is offering financial incentives for vital registration, although in a country that tries to limit family size to two children this has the potential for inaccurate reporting. Mongolia certainly seemed to be the leader in the group on the issue of data collection and is the only country with a vital registration system. They have received support from large international donors such as GAVI to fund health system strengthening and the importance of partnerships with global donor bodies was discussed. The focus for Mongolia now is on improving the quality and accuracy of data rather than collecting any at all.
The minimal acceptable level of access to emergency obstetric care was discussed, and it was agreed that the WHO minimal standard of 4 basic emergency obstetric care facilities per 500 000 population needed to be adapted to local settings. The Philippines for example with over 7000 islands or PNG with extremely poor transport infrastructure will need more facilities than this if they are to achieve a minimum standard of care.
Finally each of the seven priority countries was given a chance to revaluate and update their national strategies to reduce maternal and perinatal mortality. These were considered in terms of political commitment, technical input, human resources training and deployment, information systems, financial and support systems, supervision and monitoring of progress and the role of partnerships. From this the regional strategy for reducing the MMR will be published.
Overall I found this meeting extremely interesting and it was good to see the WHO facilitating debate between countries so as to learn from each other’s successes and failures. I hope that at the next meeting some of the excellent policy ideas discussed have been enacted and this benefit is for the women of the Western Pacific region and their babies.
Dr Jane Hirst MBBS (Hons) FRANZCOG; Representative of the Medical Women’s International Association
Ho Chi Minh City Vietnam November 2008-11-10