My previous blog drew attention to the proposed Sustainable Development Goal (SDG) for maternal health which aims to reduce the global average Maternal Mortality Ratio (MMR) to less than 70 maternal deaths per 100,000 births by 2030, with no country to have an MMR greater than 140. I argued that achieving this goal would require completely new strategies and indicators for global maternal health. Ensuring universal coverage of skilled birth attendance will obviously remain a  priority in the next 15 years because too many low-income countries have not yet achieved it. However, I suggested that the post-2015 global maternal health agenda will need to shift focus if we are serious about lowering national and global MMRs to these levels. In this blog I highlight the experience of maternal health in South Africa to support these arguments and to suggest what some of the new maternal health priorities might be as countries work towards achieving the maternal health SDG targets.

South Africa is a middle-income country with adequate resources to spend on improving population health. The return for this expenditure has remained sub-optimal in recent years as the country has grappled with post-apartheid transformation, the HIV/AIDS epidemic, a dual public and private health care system, and persistent health inequalities. Nevertheless, the national coverage of key maternal health interventions such as basic antenatal care and skilled birth attendance are over 95%, and have been fairly static at these levels for nearly two decades. Despite this the national MMR remains above 200 per 100,000 live births. Further decreases in the MMR will clearly have little to do with increasing skilled birth attendance. Rather they will depend on improving the quality and equity of emergency obstetric care and eliminating maternal deaths in HIV-positive women.

South Africa initiated a system for the confidential enquiry of all maternal deaths in 1998.The sixth triennial report of the National Committee for the Confidential Enquiry into Maternal Deaths (NCCEMD) for the period 2011-2013 was recently finalised and released. The most important causes of maternal death in this period were HIV/AIDS, obstetric haemorrhage and pregnancy-induced hypertension, which together accounted for two-thirds of all maternal deaths.

Source: NDoH Saving Mothers Report, 2014

The figure above indicates the current recommendations of the NCCEMD for addressing maternal deaths in South Africa. The NCCEMD proposes three health system priorities to improve the quality of emergency obstetric care and to decrease maternal deaths from HIV, haemorrhage and hypertension. These are:

1. Ensuring 24-hour access to well-functioning and appropriately-resourced basic emergency obstetric care  (BEmOC) and comprehensive emergency obstetric care (CEmOC) facilities.
2. Having sufficient numbers of skilled health professionals with extensive training in the management of HIV and obstetric emergencies. These include the skills for conducting caesarean sections and obstetric anaesthesia. 
3. Providing 24-hour access to rapid and reliable emergency transport systems.   

These strategies will need to be supported by improved maternal health audits and better monitoring and evaluation of maternal health programmes at all levels.  

These priorities are not new to the global maternal health agenda but clearly extend well beyond universal coverage of skilled birth attendance. National strategies will need to be targeted to local causes of maternal deaths and local health system deficiencies, but the current priorities in South African are instructive in suggesting the types of responses and strategies that may be important in achieving the new SDG goals in other countries by 2030.

However, a key concern is that such interventions will require significant additional financial, human and informational resources for both health system strengthening and for maternal health programmes in most low- and middle-income countries. The current debates about the post-2015 development goals and indicators have said little about the scale of the additional resources required to achieve the maternal health SDGs, or how these resources might be mobilised. It is urgent to start debating some of the specifics about what will need to be done to lower MMRs to below 140 in all countries, and how those interventions will be financed, if the maternal health SDG targets are to be real and realised.   

References

• Gabrysch, S., P. Zanger and O. M. R. Campbell (2012). "Emergency obstetric care availability: a critical assessment of the current indicator." Tropical Medicine & International Health 17(1): 2-8.
• NCCCEMD (2014) Saving Mothers 2011-2013: Sixth report on confidential enquiries into maternal deaths in South Africa. Short report. Pretoria, Department of Health.
• Sustainable Development Solutions Network (2015). Indicators and a Monitoring Framework for the Sustainable Development Goals. Launching a data revolution for the SDGs. A report by the Leadership Council of the Sustainable Development Solutions Network. Revised working draft (Version 7) March 20, 2015. Geneva, Sustainable Development Solutions Network.