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Management in Practice

Can We Eliminate Maternal Mortality?

The number of women who die during childbirth has been on the decline for decades worldwide. But the decrease hasn’t been evenly distributed; some regions of the globe still face significant hurdles in making childbirth safer. Yale Insights talked with Dr. Mary-Ann Etiebet ’03, executive director of Merck for Mothers, about the state of maternal health and whether eliminating maternal mortality is a realistic goal.

The number of women dying during childbirth or soon after is dropping. From 1990 to 2015, the global maternal mortality rate fell by almost half, with millions of women saved through a variety of interventions. The rapid drop has been hailed as a “worldwide public health triumph.”

But no one is celebrating yet. The reduction is far below the 75% target set by the United Nations.  More than 800 women die each day—99% of them in developing countries—with hemorrhage as the leading cause of death. Sub-Saharan Africa alone accounts for two-thirds of deaths, while another 22% occur in South Asia. “There are still about 53 million women who have no care at all at the time of delivery,” Wendy Graham, professor of obstetric epidemiology at the London School of Hygiene & Tropical Medicine, told the Guardian.

The story is different in the developed world, where the mortality rate has declined precipitously. It dropped so much in the United Kingdom that one study determined that “a man is more likely to die while his partner is pregnant than she is.”

One outlier from this trend is the United States, which has the highest maternal mortality rate among developed countries. In the U.S., the number of women dying in childbirth or soon after more than doubled between 1987 and 2011.  The reasons for this reversal are many. Women are older when they get pregnant. They face more chronic health conditions such as diabetes, hypertension, and heart disease. The prevalence of cesarean sections puts mothers at greater risk for life-threatening complications. For many women living in rural areas, the availability of healthcare, particularly hospitals with dedicated obstetric units, is on the decline. And many healthcare providers are not adequately prepared to face obstetric emergencies.

Merck for Mothers, a 10-year $500 million initiative dedicated to maternal health, includes the U.S. in its list of 30 countries to focus on. According to Dr. Mary-Ann Etiebet MBA/MD ’03, executive director of the organization, many of the interventions needed in high-mortality places such as India and Nigeria apply to the U.S.

In a conversation with Yale Insights about the state of material health, Etiebet said that 98% of maternal deaths are preventable. And no matter where an expectant mother lives, she added, the ultimate goal is the same—to entirely eliminate preventable deaths during childbirth.

Q: What is the state of maternal health around the world?

This is an issue I think that many people are not aware is still a problem. Eight hundred women every day are dying due to complications of pregnancy and childbirth. That’s one woman every two minutes. And this is not just an issue in poor countries, although obviously, a big majority of the deaths are happening there. We also see maternal mortality rising in the U.S., and we see the gap in health outcomes also widening between certain populations.

Q: Are there any particular places that you’re most worried about?

India and Nigeria alone contribute up to 20% of the maternal global death burden. So we have a number of initiatives and investments with partners that are working in those countries. Kenya also has a high maternal mortality burden, but it’s also a country that is really experimenting with innovative approaches to financing, innovative approaches to digital, and we think that by capturing some of that new innovation and applying it to the health sector, we’re really going to have a leapfrogging effect when it comes to maternal health outcomes.

Q: What is it about India and Nigeria that make it so difficult?

There are three key reasons why women are dying. One is that they’re not able to access the care that they need because they cannot get to the facilities where emergency care may be available. Two, they may not know what it is that they need to do, or they may not be aware that they need to seek medical attention. And three, when they do seek medical attention, the level of quality may not be commensurate with the need. All of those things are driving maternal deaths, but I think what we’re seeing both in the U.S. and around the world is what we’re calling the indirect drivers—social determinants of health. Do you have access to transportation? Are you stably housed? Do you have proper nutrition that reduces your risk for postpartum hemorrhage? All of these factors increase the risk for complications during pregnancy and childbirth.

Q: Do you think there will ever be a time when no women die in childbirth?

Out of the approximately 800 maternal deaths each day, most are preventable if women have access to quality healthcare. In the U.S., the CDC recently came out with a report whose findings included that about 60% of the maternal deaths that we’re seeing in the U.S. are preventable. Our goal is to completely eliminate those preventable maternal deaths—and we think we can get there. It’s going to take a lot of commitment. It’s going to take partnerships, particularly partnerships across sectors—that’s public sector, private sector, civil society. It’s going to mean that we have to think about new ways of actually scaling interventions that we know work. For example, in the U.S., Merck for Mothers works with partners not only to understand what it is that is driving maternal deaths, but we’re also working with partners to develop the tools, resources, training programs that improve quality of care in facilities. And another key pillar of our work is how we actually empower women so that they can be effective advocates for their health.

Q: If we were to go over to Nigeria, what would your programs look like?

We’re actually in 30 countries working with over 50 partners on about 100 distinct programs. And they run the gamut, but in terms of, again, our three pillars: one, the programs that we do that empower women. So that’s bringing information to women so that they understand the quality of care, they know where to find high quality care, and they can actually rate quality care and give that feedback back to the providers. Many of those programs are laid on digital platforms so that that information can get directly to women and their families.

A second area of investments that we have is around equipping providers. At Merck, we’re known for inventing for life. And part of what we want to do is invent new tools and resources that providers can have at their fingertips to increase quality of care. So again, that runs the gamut from training, resources, new interventions, new medicines.

One partnership we have is with the WHO and Ferring Pharmaceuticals to bring what’s known as heat stable carbetocin to women all around the world. The number one killer of women is postpartum hemorrhage. The current treatment we have for that, oxytocin, needs refrigeration to remain effective. Many of these women are giving birth in facilities that don’t have access to electricity. That medicine, that doctors, or midwives, are relying on to prevent postpartum hemorrhage would not be effective for those women. And so in partnership with the WHO and Ferring Pharmaceuticals we have funded a phase three clinical trial to get heat-stable carbetocin out in the field.

Q: Serena William’s pregnancy scare shined a light on the larger issue of maternal health in the U.S. What is your view of the issue in America? Why is maternal mortality on the rise here?

Stories such as Serena Williams’ bring into focus what’s happening to hundreds of women around the U.S. And I’m so glad that she shared her story with the world. What it shows is that maternal mortality strikes anyone at anytime, anywhere. Your fame, your education, your income levels—none of those ultimately can protect you. And so we have to prepare everyone for those circumstances. What we know about maternal mortality in the U.S. is that we see it more often with women who have increasing prevalence of comorbidities. We see it more often in women who have decreased access to quality of care. But in Serena’s particular situation, I think what it highlighted is that women need to understand, need to be aware of, what the risk factors are of maternal mortality. Because she had a history of pulmonary embolism, she was able to recognize the signs and symptoms. And it was her self-advocacy that got the care team working on the appropriate treatment for her.

For lots of women who may not be aware of those signs and symptoms, you can think about what kind of a tragic outcome there would have been. We’ve partnered with the Association of Women’s Health, Obstetric, and Neonatal Nurses to develop education materials both for nurses and for women as they’re being discharged from the hospital so that they are aware of signs and symptoms of possible postpartum emergencies and they can seek the appropriate care.

Q: One of the things that was so shocking about her story was that the doctors had basically no idea what was going on.

The Association of Women’s Health Nurses did a survey of nurses who were working in labor and delivery. They found that at least half of those nurses were not aware that maternal mortality was rising in the United States. More than half were not aware what the top causes of maternal mortality were and more than half were spending less than five minutes actually counseling women on risk factors and signs and symptoms. We need to bring more attention to this issue because only if people are aware that this is a possibility will they be mobilized to take action. We’ve seen that when that type of work is being done in hospitals, it actually has impact. One of the other things that Merck for Mothers has done is partner with different organizations in New York State and in California to implement what we call safety bundles around obstetric emergencies and hospitals. This is a checklist of best practices as well as instructions for the team, the whole multidisciplinary care team, to be mobilized quickly, to respond to these emergencies.

Q: We see in many rural areas that healthcare is becoming harder and harder to get. Hospitals are closing. What do we do about this situation?

The same issues that are killing women in rural areas in Zambia are killing women in the United States. A huge problem is the fact that they are far away from emergency obstetric services. In rural Zambia, women are walking 8 to 12 kilometers to get to a facility. One of the ways that we’ve approached tackling that issue is maternity waiting homes. We’ve invested in building maternity waiting homes near facilities in countries like Zambia, so that as women are approaching their due date, they’re able to stay in the maternity waiting home so they’re closer to the facilities and emergency care. There was a recent New York Times article about similar types of waiting homes in Alaska .

Q: The World Bank has estimated that there’s a $33 billion gap in terms of financing in order to meet the sustainable development goals for maternal and child health. How do you close that gap?

Unless we crowd in more resources, specifically private sector and private capital, to this issue, we’re not going to get to that goal. MSD for Mothers [as the initiative is known outside the U.S. and Canada] was in Davos at the World Economic Forum, where we highlighted two new innovative financing partnerships. One is with the World Bank through its Global Financing Facility. We were the first private sector contributor to its trust fund, which helps it work very closely with governments around the world to identify high impact investments that are going to reduce maternal mortality.

The second partnership we highlighted was the launch of our new development impact bond, which is called Utkrisht, Hindi for excellence. This is a partnership with UBS Foundation as well as USAID. The bond is designed to infuse capital with the local private providers in the state of Rajasthan in India so that they are able to invest in quality improvement and meet quality accreditation standards that have been set by the government. Through that initiative, we’re hoping that we will be able to increase the access to quality maternal healthcare for over 600,000 women and over a period of five years, save up to 10,000 lives.

Q: The refugee crisis in Europe and the Middle East is also a maternal health crisis. How are organizations like Merck for Mothers able to help?

The situation is dire. There aren’t readily available maternal health services; Doctors of the World has to bring those services to the camps with mobile health units and through the volunteer work of physicians, nurses, midwives, and other health workers. We need to have more than a temporary solution for that. We need to think about how we have sustainable solutions for healthcare access that are integrated into the larger healthcare delivery system. Also, we need to understand that many of these women have had very traumatic experiences. Their needs are not just specifically around pregnancy and childbirth. We need to think about how we provide holistic, comprehensive, integrated services, including services around mental health.