On March 20, 2019, Doctors Without Borders/Médecins Sans Frontières (MSF) hosted a live webcast panel discussion with four experts on global women's health to discuss what progress we have achieved and what major challenges remain to reducing maternal mortality.
"There has been a drop globally in maternal death, about 40 percent between 1990 and 2015," said Rachel Jones, the moderator of the panel and a journalist who has reported on maternal mortality in the United States and globally. "But, in the places where MSF works, we are still seeing very high maternal mortality rates."
"There is pretty much a consensus in what we need to get reductions in maternal mortality," panelist Lynn Freedman said. "But to do that we need strong health systems - and therein lies both the solution and the challenge." Freedman currently directs the Mailman School's Averting Maternal Death and Disability (AMDD) Program.
MSF works in some of the countries with the world's highest mortality rates (as well as broken or inadequate health systems), including Sierra Leone, Chad, Central African Republic, Afghanistan, Pakistan, and Yemen. The most common causes of maternal death are: postpartum hemorrhage (bleeding), reproductive tract infections, eclampsia, unsafe abortion, obstructed labor, and serious infectious diseases.
Using the internationally recognized "three delays" model, MSF projects focus on the three points at which pregnant women might face a delay in accessing the care they need to deliver safely:
Some ways MSF addresses these delays include: outreach to inform women of our services and why they should seek care; providing antenatal care services closer to where women live via mobile clinics and other decentralized locations; maternity waiting homes for women in the last month of pregnancy; supporting ambulance services; and emergency obstetrics care.
"It's not just having an operating room," said MSF midwife Erika Sawyer. "It's having an operating room with sterile equipment that's available 24/7, that has all of the supplies you need, and blood in the blood bank. That is the kind of quality care that we're trying to focus on more and more right now."
"Access is a huge issue," said MSF midwife Liza Ramlow. "In northern Zambia, for instance, where you would have to get on a bicycle for two to four hours in order to get to a small, rural health center, where there certainly wouldn't be a cesarean section, for example, but you maybe could get transport to the district hospital, where there would be one."
A woman's previous experiences with inadequate or disrespectful care at local clinics can also prevent her from coming to a facility to deliver. "It's essential that we have respectful maternity care," said Ramlow. "There are lots of women who do not feel welcome in the systems that we have now."
In many places with broken health systems, women rely on traditional birth attendants (TBAs). With an uncomplicated pregnancy and delivery, an attended home birth can go well, but when a woman needs skilled care, it's a different story. In South Sudan and Bangladesh, Ramlow worked alongside TBAs who were trained by MSF to identify and recognize the signs of complications during delivery and to help those women reach the MSF hospital quickly.
The panel highlighted the importance of women's access to contraception, which historically was not seen as a medical humanitarian priority. "We know that if all women who wanted contraception--which is several hundred million--had access to it, maternal mortality would actually be reduced by about 30 percent," said Feedman. "If you don't get pregnant, you're not going to die in pregnancy or childbirth." Sawyer and Ramlow pointed out that MSF has made strong progress in offering women access to a variety of modern contraception methods in recent years.
Unsafe abortion as a forgotten emergency was also discussed. It remains one of the five leading causes of maternal mortality. "I lived in Kenya for eight years," said Jones. "I heard some of the most horrifying stories you can imagine about young women--women of all ages really--having illegal, backstreet, horrifying abortions. Seven women every day die in Kenya and more than 320 were injured every day from unsafe abortion."
Globally, the number is far higher. According to a comprehensive report published by the Guttmacher Institute in 2018, at least 22,000 women and girls die each year after having an unsafe abortion, but the actual number of deaths is unknown since so many of them are never reported. "We're in the time of the Global Gag Rule right now, and MSF- because we don't take money from [the US government]--can say whatever we want," said Sawyer. "It feels extremely invigorating and refreshing because we're one of the only NGOs [nongovernmental organizations] being very active about the fact that we provide safe abortion care as a means to reduce maternal mortality, and that it's vital."
Capacity-building by training local staff is also important in the places where MSF works. In South Sudan, Sawyer provided Advanced Life Support Obstetrics (ALSO) training to South Sudanese staff. ALSO is an internationally recognized emergency obstetrics training program that MSF has implemented in many projects, focusing on managing preeclampsia, hemorrhage, and other life-threatening situations.
"We see maternal mortality intrinsically linked to women's status within society," said Sawyer. "Medically, we can provide a band-aid, but if we want to see real change, women's status has to change. There are incredible women everywhere . . . already working to make those changes."
Moderator Rachel Jones, Media Consultant and Freelance Writer, has worked as a journalist and media trainer/advisor for the last 20+ years in the US and Africa, for companies and media outlets including National Geographic, The Detroit Free Press, National Public Radio, Internews, the International Center for Journalists and Kenya's Nation Media Group.
Panelist Lynn P. Freedman, JD, MPH and professor of population and family health at Columbia University, currently directs the Mailman School's Averting Maternal Death and Disability (AMDD) Program, a global program of research, policy analysis, and technical support.
Panelist Erika Sawyer, MSF Midwife, is a Certified Nurse Midwife (CNM) practicing in San Francisco, California. She has completed nine assignments with MSF, almost half of which have been in South Sudan. She has also worked in Central African Republic, Kenya, Tanzania, Mozambique, and most recently in Honduras.
Panelist Liza Ramlow, MSF Midwife, "retired" in 2010 to fulfill a longtime desire to work as a midwife in international settings. Liza has completed ten assignments with MSF in Bangladesh, Italy (where she worked on MSF's search and rescue boat in the Mediterranean), South Sudan, Central African Republic, Burundi, Democratic Republic of the Congo, Zambia, and Nigeria.