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In Bangladesh and more than 50 other developing countries, a pregnant woman's chance of surviving childbirth is improving with the help of a program started by the Mailman School of Public Health four years ago.

As many as 20,000 women in Bangladesh who develop complications during childbirth, such as hemorrhages, obstructed labor or infections, die each year because major urban hospitals are too far away and local government hospitals are not trained to perform emergency Caesarean sections, provide blood transfusions and carry out other emergency procedures. Globally, more than 500,000 women die each year and millions more are disabled from such obstetric complications. Developing countries account for 99 percent of these deaths.

But now, through the Mailman School's Averting Maternal Death and Disability (AMDD) program, services in existing facilities are being improved so that the procedures that can treat these childbirth complications can be performed. About 300 people from the countries involved in the program – which started in 1999 with a $50 million grant from the Bill and Melinda Gates Foundation – gathered in late October in Malaysia to share experiences and expertise.

"The conference was a great success because everyone heard about the progress of the many projects," says Dr. Deborah Maine, professor of clinical public health at the Mailman School and director of AMDD. "Before this, other maternal health conferences stressed the importance of the problem, but there was no coordinated effort to move programs forward. There are now more than 85 AMDD-supported projects."

Bangladesh's government, in collaboration with UNICEF, for example, is implementing a nationwide program supported by AMDD. The goal is to ensure availability of 24-hour emergency obstetric care services in all of its 59 district hospitals, which have about 50 beds each, and 120 of the country's subdistrict health complexes. More women are receiving services since the start of the program – district hospital deliveries have increased 54 percent; admissions of complicated cases have increased 127 percent; and Caesarean deliveries are up 56 percent.

Health care workers in Bangladesh, Afghanistan, Bhutan, India, Nepal, and Pakistan received competency-based training from JHPIEGO (a reproductive health organization affiliated with Johns Hopkins University) supported and guided by AMDD, says Dr. Zafarullah Gill, associate research scientist at the Mailman School and associate director of AMDD, and George Patterson, AMDD program coordinator.

Although the program officially started in 1999, the concepts behind it have been developing since 1985 when Dr. Maine and Dr. Allan Rosenfield, dean of the Mailman School, published a paper in Lancet, "Maternal Mortality – a Neglected Tragedy: Where is the M in MCH (maternal and child health)?" The paper detailed the need for emergency obstetric care to decrease maternal mortality in poor countries. At that time, many international health leaders mistakenly believed that emergency obstetrics care for expectant mothers was not necessary because good primary care could prevent complications. It is now known and accepted that it is very difficult to predict who will experience complications during childbirth. Women in perfect health develop pregnancy and delivery problems in all countries, but in developed countries they receive life-saving care.

"Our 1985 paper began to change the paradigm of protecting maternal health. But the Gates Foundation grant really helped us make the next step of providing financial and technical support to programs aimed at improving services to treat maternal complications," Dr. Maine says.

Rather than put Columbia staff overseas, the program involved major international organizations such as UNICEF, the United Nations Population Fund (UNFPA), CARE, Save the Children, and other nongovernmental organizations.

"We saw the opportunity to add emergency obstetric care at the district hospital level to existing, often village-level, programs run by UNICEF, Save the Children, and CARE. The majority of women in developing countries deliver their babies at home, sometimes with a traditional birth attendant or a relative in attendance but they need a place to go for emergency health care when complications arise," Dr. Rosenfield says.

The program consists of three parts – medical, management and human rights. "We feel that the death of women during childbirth is a basic human rights violation because it is well-known how to save them but the health care systems in many countries are not organized to prevent these deaths," says Lynn Freedman, associate professor of clinical public health and senior adviser on human rights with AMDD.

She noted that reducing maternal mortality was set as a global goal in 1987 and then reiterated as one of the United Nations Millennium Development Goals – a set of initiatives to greatly reduce poverty-related death and illness in poor countries by 2015 – to reduce maternal mortality by 75 percent. "Such a reduction can't be done without widespread access to emergency obstetric care and functioning national health systems, which are global as well as national responsibilities," Ms. Freedman says.

Countries and organizations now are extending efforts beyond the initial AMDD projects. Care for obstetric emergencies is included in new reproductive health programs in Afghanistan and China; UNICEF and UNFPA are assessing needs in additional countries in Central America, Africa and Asia; and CARE and Save the Children are incorporating attention to obstetric services in their new reproductive health projects.

"At the Malaysia meeting, it was exciting to see how the concepts developed at Mailman have taken hold and how organizations have taken the concepts that we have been promoting and making them their own," Dr. Rosenfield says.

—Matthew Dougherty