Levels and Causes of Maternal Mortality and Morbidity

Filippi V, Chou D, Ronsmans C, et al. Levels and Causes of Maternal Mortality and Morbidity. In: Black RE, Laxminarayan R, Temmerman M, et al., editors. Reproductive, Maternal, Newborn, and Child Health: Disease Control Priorities, Third Edition (Volume 2). Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2016 Apr 5. Chapter 3. Available from: https://www.ncbi.nlm.nih.gov/books/NBK361917/ doi: 10.1596/978-1-4648-0348-2_ch3.

Reproductive, Maternal, Newborn, and Child Health (RMNCH) covers the health concerns and interventions across the life course involving women before and during pregnancy; newborns, that is, the first 28 days of life; and children to their fifth birthday. The volume identifies 61 essential interventions and because of the timing of their delivery in the life course, groups them into three packages: 18 for reproductive health, 30 for maternal and newborn health, and 13 for child health, although some interventions, such as vaccines for immunization, have multiple components. The volume considers the health system needs for implementing these interventions in health service platforms in communities, in primary health centers, and in hospitals and the cost-effectiveness of interventions for which data are available. This chapter summarizes the volume and considers the potential impact and cost of scaling up proven interventions to reduce maternal, newborn, and child deaths and stillbirths.

The annual number of global maternal and child deaths has dropped markedly in the past 25 years, yet the rate of reduction in many countries has been too slow to achieve Millennium Development Goals 4 and 5 by 2015.

Progress could be accelerated by scaling up integrated packages of essential interventions across the continuum of care for RMNCH. These interventions are highly cost-effective and result in benefit-cost ratios of 7–11 to 2035 (net present value in U.S. dollars of benefits to costs).

Scaling up all interventions in the packages of maternal and newborn health, plus folic acid before pregnancy, and child health from the existing rate of coverage to 90 percent would avert 149,000 maternal deaths; 849,000 stillbirths; 1,498,000 neonatal deaths; and 1,515,000 child deaths, representing the impact in 2015 at current rates of pregnancy, birth, and mortality.

The reproductive health package is particularly important for providing contraceptive services. Addressing 90 percent of unmet need in 2015 would reduce annual births by almost 28 million, which would consequently prevent 67,000 maternal deaths; 440,000 neonatal deaths; 473,000 child deaths; and 564,000 stillbirths from avoided pregnancies.

Individual interventions that have the highest impact on deaths are provision of contraception; management of labor and delivery; care of pre-term births; treatment of severe infectious diseases, including pneumonia, diarrhea, malaria, and neonatal sepsis; and management of severe acute malnutrition.

The three packages of reproductive, maternal and newborn, and child health interventions have an annual incremental cost of US$6.2 billion in low-income countries, US$12.4 billion in lower-middle-income countries, and US$8.0 billion in upper-middle-income countries. The average per capita cost of these three packages is US$6.7, US$4.7, and US$3.9 in low-, lower-middle-, and upper-middle-income countries, respectively.

These packages of interventions are delivered through three key service platforms: community workers and health posts, primary health centers, and hospitals (first level and referral). Community and primary health center platforms could reduce 77 percent of maternal, newborn, and child deaths and stillbirths that are preventable by these essential interventions in the maternal and newborn health and child health packages. Hospitals contribute the remaining averted deaths through more advanced management of complicated pregnancies and deliveries, severe infectious diseases, and malnutrition in these calculations. Contraceptive services are considered to be almost entirely delivered at primary health centers.

Weaknesses in RMNCH delivery platforms, including limited access to care, poor quality of services, and shortages of health workers or medicines, are a major barrier to improving RMNCH outcomes. To overcome these weaknesses and expand access to RMNCH services, innovative delivery approaches are being deployed, such as task-shifting to other cadres of workers, household visitation, community mobilization and service delivery, financial incentives for households and health workers, and supervision and accreditation.

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