Natasha Hezelgrave from Kings College London reviews ‘Maternal and Perinatal Health in Developing Countries’
Maternal mortality represents one of the starkest disparities in health outcomes between developing and developed countries. An estimated 358,000 maternal deaths occur annually and over eight million women suffer from illness, infection or injury as a consequence of pregnancy or childbirth. Perinatal mortality, intrinsically linked to survival of the mother, is equally shocking; six million babies are estimated to die each year, the majority of these in the developing world.
Since the 1980s, the international recognition that reducing maternal mortality rates in the developing world should be a commitment and a priority has strengthened. Yet this process has been far from perfect. Maternal Child Health (MCH) policy tended to address maternal health as a by-product of interventions to improve child health, leading Rosenfeld and Maine in 1985 to ask ‘where is the M in MCH?’ There was a failure not only to recognise that the causes and solutions to child and maternal morbidity and mortality were different, but also that whilst the causes of maternal mortality cannot always be predicted or prevented, death can be averted if complications are treated.
With maternal mortality rhetoric evolving considerably, the millennium development goals (MDGs) established by the United Nations in 2000 placed maternal mortality as a core development indicator, and the last two years have seen an unprecedented level of support and activity to accelerate progress towards MDGs 4 and 5, as well as a recognition that reduction in maternal mortality will facilitate enormous gains in the other development targets, particularly child health, poverty reduction and gender equality.
‘Maternal and Perinatal Health in Developing Countries’ edited by Julia Hussein, Affette McCaw-Binns and Roger Webber places maternal and perinatal health firmly in the centre of the global public health arena. The book, with chapters written by authors from the low and high-income countries, clearly explains the current global situation where maternal and perinatal health is integral to population health, a marker of the performance of a complex health system and of development itself. Key trials and strategy, as well as barriers preventing progress, are presented with pertinent case studies to illustrate country experiences, providing an important and embarrassing reminder of the global inequity between the rich and the poor.
What sets the book apart, however, is its practicality. Traditionally maternal public health texts have been consigned to a conceptual chapter within general public health texts, or been delivered as a ‘do-it-yourself’ master class for practising obstetrics in low-income countries. The authors of ‘Maternal and Perinatal Health in Developing Countries’ have managed to create a ‘how-to’ manual with a difference. Whilst not only exploring the conceptual basis of topics such as the financing of maternity services, quality of care, transport and referral systems and implementing clinical interventions, each chapter offers practical advice regarding how to address barriers and design maternal health systems, incorporating evidence-based recommendations for improved maternal and perinatal health.
The authors do not shy away from clinical practicalities; indeed a chapter is devoted to common obstetric and neonatal morbidities and mortalities and the often simple proven interventions that save lives. This relative clinical under-representation is by no means a shortfall of the textbook. Whilst acknowledging ‘what works’ to save lives, the authors consider how to provide this care within a context of the wider health system rather than taking a vertical approach to health intervention. Without access to a health centre, means of transport and a skilled birth attendant, not to mention prevention and treatment of malnutrition, anaemia and HIV, any single intervention to prevent or treat post partum haemorrhage (the leading cause of maternal death) will not make any significant impact for a pregnant women living in poverty in the developing world. Moreover, without the education and autonomy to make decisions about their own health and family planning, and without the political will to underpin improvements in maternal health, a future generation will be condemned to a cycle of poverty, ill health and maternal and perinatal morbidity and mortality at unacceptable levels.
This book is timely and important. It is not just an easy to use reference text for those working in maternal and perinatal global health. Rather, it is a call to arms for all obstetric and neonatal trainees and clinicians, for whom maternal mortality is a devastating but rare event, to greater understand this global inequity and act as advocates for women, for whom maternal mortality is a preventable but ever present reality. I urge you to read it.
Natasha Hezelgrave is a clinical research fellow in the Women’s Health Academic Centre, Kings College London. She has worked and taught extensively in Sub-Saharan Africa and India. Her main research interests are safe motherhood in low-income settings, pre-eclampsia and preterm birth. She is currently coordinating a multi-country Bill Gates Foundation funded research project aimed at improving detection of pre-eclampsia in rural sub-Saharan Africa. The author declares no conflict of interest.
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