Appendix E
Dissenting Note

Abhay Bang, M.D., M.P.H.

Gadchiroli, India

This report recommends universal availability of skilled birth attendants (SBA) and access to referral care as the two main interventions to improve pregnancy outcome in the developing world. In doing so, the report is following the current opinion in the international organizations. Donor agencies and policy makers in developing countries will invest billions of dollars and could be putting the lives of millions of women at stake. These recommendations have implications of mammoth proportions.

While I agree with the goal of providing better skilled care to all mothers and neonates, some questions need to be asked before a colossal amount of resources are committed to the approach recommended in this report.

  1. Certain levels of development and availability of infrastructure—roads, cars, telephones, literacy, skilled manpower and clinics/hospitals—are necessary for implementing this approach. Will this medical approach, which succeeded in the past in developed countries, work in the absence of such societal development in developing countries? Can it be transplanted successfully in the very different economic and cultural settings?

  2. Where is the definitive evidence—randomized, controlled field trials—that such an approach reduced the maternal mortality in developing countries? The report says that no such trials have been conducted so far. Mere historical evidence from Sweden or being “sensible” are inadequate evidence. Many earlier policies failed because they were not field tested rigorously. Is a similar error being committed again?



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Improving Birth Outcomes: Meeting the Challenge in the Developing World Appendix E Dissenting Note Abhay Bang, M.D., M.P.H. Gadchiroli, India This report recommends universal availability of skilled birth attendants (SBA) and access to referral care as the two main interventions to improve pregnancy outcome in the developing world. In doing so, the report is following the current opinion in the international organizations. Donor agencies and policy makers in developing countries will invest billions of dollars and could be putting the lives of millions of women at stake. These recommendations have implications of mammoth proportions. While I agree with the goal of providing better skilled care to all mothers and neonates, some questions need to be asked before a colossal amount of resources are committed to the approach recommended in this report. Certain levels of development and availability of infrastructure—roads, cars, telephones, literacy, skilled manpower and clinics/hospitals—are necessary for implementing this approach. Will this medical approach, which succeeded in the past in developed countries, work in the absence of such societal development in developing countries? Can it be transplanted successfully in the very different economic and cultural settings? Where is the definitive evidence—randomized, controlled field trials—that such an approach reduced the maternal mortality in developing countries? The report says that no such trials have been conducted so far. Mere historical evidence from Sweden or being “sensible” are inadequate evidence. Many earlier policies failed because they were not field tested rigorously. Is a similar error being committed again?

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Improving Birth Outcomes: Meeting the Challenge in the Developing World What will be the space for personal choice? Who will decide as to where and how women should deliver? Will this decision for every woman in the developed as well as developing countries be made by the professionals and policy makers alone or will women and their families have a choice? Who will finance the enormously costly professional model of maternal-neonatal care? Will the people be willing to pay the cost because the “experts” want them to be served only by the professionals? At the current maternal mortality ratio (MMR) of 5 per 1000 deliveries, people in many developing countries may consider a pregnancy and delivery to be 99.5% safe. Will they like to put their money for making it safer? Is saving mothers by the SBA approach the most cost-effective option to save mothers? A country may like to put its scarce resources in TB or malaria control or tetanus immunization to save mothers. Has a rigorous comparison of the cost-effectiveness of different approaches been made? The inference that the training of traditional birth attendants (TBAs) did not succeed in reducing maternal mortality is a half-truth. The other half is that TBAs were not backed by emergency obstetric care. In the absence of referral linkages to manage the complicated deliveries the training of TBAs did not succeed in isolation. Not surprising. Even the skilled birth attendance may not result in the reduction of maternal mortality in the absence of access to emergency obstetric care. The disappointment about TBAs is due to a wrong expectation. When the unskilled birth attendants were backed by the access to referral care (Model I), the maternal mortality ratio reduced in rural China and Brazil to 115 and 120, respectively (Table 5-1 in the report). The report assumes that what is best for mothers is also the best for neonates. Hence SBA + referral care is recommended as the main strategy for neonates as well. This may not be true. The current level of MMR and the causes of maternal deaths may necessitate access to hospital-based professional care for preventing maternal deaths. But neonatal deaths can be prevented and NMR brought down without dependence on hospitals. In 1996 Sri Lanka achieved an NMR of 12.5 per 1000 live births when the entire country had only 40 neonatal intensive care incubators, 54 pediatricians (1:34,000 population) and 77 obstetricians (1:24,000) (de Silva, 1999). The Gadchiroli (India) trial, described in this report (Box 3-1) has shown that training village level functionaries to deliver home-based neonatal care (including some skilled functions) reduced the NMR by 62 percent at a very low cost of $5.30 per neonate, and $97 per averted fetal/neonatal death. Since nearly 60 percent of neonatal deaths occur after the first day of delivery, when the neonates are usually at home, and since prevention of neonatal deaths needs simpler technology, most of the neonates can be managed at home as well. The NMR can be reduced at a very low cost

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Improving Birth Outcomes: Meeting the Challenge in the Developing World without access to hospital care. Hence the interventions to reduce the MMR and the NMR need not follow the same approach. Home-based or community-based approach is by far more cost-effective than the estimated cost-effectiveness of providing the recommended package to mothers and neonates, that is, $1,000-3,000 per averted maternal or neonatal death. The World Bank report 1993, Investing in Health, estimated the cost of providing maternal care to be $3.80 per capita or $90 per mother or $30-50 per disability-adjusted life year saved (World Bank, 1993). The total estimated cost of public health and clinical services in low income countries was $12 per capita. Many developing countries may not be able to devote the required resources for this recommended approach, as it may need $3.80/12, or 30 percent of their total estimated cost of health services, but it will avert only 4 percent of their disease burden (World Bank, 1993). Many less developed countries may be satisfied at this stage to provide the Model I type of care, and reduce the MMR to 115, as in rural China or Brazil (Table 5-1). The incremental gains of the Model III (MMR reduced from 50 to 43 in Malaysia) seem low. Moreover, the operational problems of implementing these models (i.e., training of SBAs, retaining them in rural areas, cost) seem difficult to surmount. The government of India tried to introduce Model II in the rural area in the entire country nearly 20 years ago, and yet, only 15 percent of deliveries are conducted by nearly 100,000 auxiliary nurse-midwives posted in rural areas. After the failure to shift to Model II, the government of India decided 3 years ago to aim for nearly 100 percent institutional deliveries (Model III). Within 2 years, it was found to be unrealistic, and had to be scaled down. The committee report fails to acknowledge or analyze this gigantic failure in India of the policy that this report now recommends. Even if the developing countries set the long-term goal of SBA and access to referral care to all mothers, what about the immediate future—the next 5 to 10 years? Globally nearly 60 percent of births occur today at home, most often attended by TBAs or family members. This situation, which will not change immediately, demands that an intermediate feasible goal be accepted and we plan to work with both the TBAs and SBAs during the transition period. If the mothers and grandmothers can be involved and educated, why not TBAs, as well, who are the community grandmothers? Though they are not the ideal personnel, they cannot be ignored or bypassed. Even in the United States, 52 percent of the population seeks help from the healers of alternative/complementary systems, inspite of the availability of highly evolved services of modern medicine. The report discusses the problem of maternal deaths caused by not having access to safe abortions, but it fails to recommend this simple, safe, and effective method to reduce abortion-related and fertility-related mater-

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Improving Birth Outcomes: Meeting the Challenge in the Developing World nal deaths. Many countries have legalized the access to safe abortion, and such service should be recommended where it is politically acceptable. The policy makers and donor agencies need to consider these issues, ask for the evidence that the recommended solution is acceptable to people, feasible to implement, effective in reducing maternal and neonatal deaths, and is more cost-effective than other interventions. Recommendations based on what appears “sensible” but, not tested in large field trials may fail to produce the desired results, leading to one more round of disillusionment. Didn’t it happen many times in the past? Obviously, we can not generalize and push for one universal health care solution. The recommended professional model of maternal-neonatal care is so resource-intensive that it may not be possible to provide that sort of care to 6 billion people. It also may not be the most cost-effective or acceptable option. Hence, I recommend that: No single model of maternal-neonatal care is appropriate for all countries. For some regions and countries the Model I, that is, home delivery by nonprofessionals backed by access to good-quality emergency obstetric care, may be one of the options at present, at least for some period. In the spirit of the Alma-Ata global declaration, and in respect to the social and cultural norms in developing countries, the efforts should be to provide maternal and neonatal care as close to community as possible, preferably at home. The professional/institutional model can be recommended only after its cost-effectiveness, feasibility, and consumer acceptance in developing countries is proved by controlled field trials and countries have resources to implement that model. Access to safe abortion should be available to all women who want it. REFERENCES de Silva, DGH. 1999. Perinatal care in Sri Lanka: secrets of success in low income country. Seminars in Neonatology 4(3):201–207. World Bank. 1993. World Development Report: Investing in Health. Oxford University Press. P. 117.