Maternal health has improved in most regions of the world, with far fewer women dying during pregnancy and childbirth than 20 years ago.
Progress in sub-Saharan Africa, however, has been much slower. HIV and complications of childbirth are the leading causes of death among reproductive age women around the world, but above all in this region. Being pregnant in sub-Saharan Africa is often a dangerous medical condition. In Zambia, women who have given birth are often greeted with a Bemba expression of relief and surprise: “Mwapusukeni.” Translated it means, “You have survived!”
That greeting is becoming more commonplace these days, which is another way of illustrating a basic truth: positive change can happen quickly when the right actions are taken to improve maternal health.
The Saving Mothers Giving Life Initiative (SMGL), a public-private partnership that includes CDC, USAID, and many others working together with the governments of Uganda and Zambia, recently released astonishing findings that document a 30% reduction in maternal mortality in one year in the four districts in Uganda where the program is operating.
In Zambia, maternal mortality in health facilities in four districts also fell by 30% in one year. Change this rapid is unheard of. It happened because the initiative used a comprehensive district-wide approach to ensure 1) that communities supported pregnant women to increase the likelihood of receiving skilled care during childbirth, 2) that health facilities had the supplies and medications needed to treat women who developed emergencies during pregnancy and post-partum, and 3) that health personnel were properly trained to provide quality care during emergencies including doing C-sections. (Read the SMGL report and other CDC blogs about SMGL.)
The danger for pregnant women with HIV is even higher. They are six to eight times more likely to die during pregnancy and childbirth than other women.
That reality is important at any time, but it comes into clearer focus and prominence this week on International Women’s Day (March 8).
Worldwide, 17.7 million women are living with HIV. Most are of reproductive age and most of them reside in sub-Saharan Africa. That’s bad enough. Here’ the kicker: while estimated maternal mortality ratios have been cut almost in half over the past 20 years worldwide, maternal mortality actually appears to have increased in eight countries in sub-Saharan Africa with high HIV prevalence. The HIV epidemic is an important reason maternal mortality has not decreased much—or has even increased.
That much is clear and it’s the reason CDC and other partners are re-doubling efforts to better understand and overcome the complex mix of medical, cultural, and institutional forces that will have to be addressed if pregnant women living with HIV are to survive. Pregnant women with HIV face the same risks that all pregnant women do—and more actions like the Saving Mothers Giving Life Initiative are critical to saving mothers’ lives.
But women with HIV face additional risks and it is those challenges and possible responses that are highlighted in a recent paper I co-authored with Tami Kendall from Harvard’s School of Public Health.
During pregnancy, women with HIV are more likely to die from malaria, TB, pneumonia, and from puerperal sepsis. It is likely that HIV treatment earlier during pregnancy will improve survival. However, in 2012 only 49% of pregnant women in Africa were tested for HIV. And not all women with HIV received the treatment they needed. There are many obstacles to receiving care, but HIV stigma and mistreatment is an important reason that women do not seek the care they need.
There is good news here too. In June 2013 the World Health Organization released new guidelines that call for the initiation of HIV treatment for all pregnant and breastfeeding women with HIV and continuing it lifelong, regardless of their immune status. The challenge is to rapidly scale up testing and treatment during antenatal care. We know it can be done because it was done successfully in Malawi. (Read the related MMWR article to learn more.)
Nevertheless, only time will tell whether women remain on treatment or whether social factors such as stigma impede adherence to treatment in Malawi, as we know they do in other settings. The role of the community in supporting women with HIV is vital as is engaging men in the care of their wives, and of themselves if they too are living with HIV. Likewise ensuring that health workers are trained to treat people with HIV with respect will eliminate an important obstacle to attending health care services.
As we conclude in our 106-page paper entitled Research and Evaluation Agenda For Maternal Health and HIV in Sub-Saharan Africa, “Improving maternal health in the context of the sub-Saharan African HIV epidemic requires greater understanding of the relationships between HIV disease and maternal morbidity and mortality, integrated and effective responses by the health system, and a social context which promotes quality care and encourages use of maternal/child health and HIV services.”
It seems straightforward—more high-quality services and easier access to care will yield positive results. And while that is true, the work also emphasizes a number of questions that need answers if the problem is to be fully addressed.
Some of them are purely clinical. Such as, how does HIV treatment (known as antiretroviral treatment or ART) and the new treatment guidelines in particular, affect rates and causes of maternal morbidity and mortality? Will ART alone reduce the risks and make them comparable to those of other women?
Or does the timing for when ART begins and the therapy’s duration affect mortality rates in pregnant women?
There are additional questions that blend clinical concerns with logistical challenges and limited funding. A prominent example is how can all the necessary services—including malaria prevention, TB screening and treatment, HIV treatment, and all the routine antenatal care screening and treatment—be most effectively provided by often already overloaded health workers? What is the best way to integrate services?
We know the importance, for example, of non-clinical work, such as diluting the still widespread and potent discrimination against people who have AIDS and are HIV-positive. That cultural reality often presents a sturdy barrier even for people who want treatment.
Other important questions include what can be done to encourage greater participation by men in maternal and child health activities? How can more men be encouraged to support women who are HIV positive? How can the stigma surrounding HIV be weakened to “promote respectful maternity care” for women who need it? What tools can be used to increase community and peer support for pregnant and postpartum women?
We also can’t forget another crucial question that must be addressed so that political and financial support is maintained. The question is this: how do we evaluate new programs and responses so that their impact on maternal illness and death can be measured and understood and so that good practices can be preserved and less effective ones dismissed or modified?
CDC supports efforts to answer these questions—and more—with data and proven science. We also support efforts to achieve goals established globally as well as by the U.S. government to reduce maternal mortality and ensure that people with HIV receive the treatment they need. CDC is working with sub-Saharan African countries to improve counseling and testing for pregnant women, improve antenatal care, provide HIV treatment during antenatal care to those with HIV, and eliminate maternal-to-child transmission of HIV.
Like the larger battle against HIV/AIDS, finding answers for helping pregnant women who are living with HIV is complicated and challenging. But progress is being made and lives are being saved. That’s what draws me to this battle and what keeps me—and CDC—focused on a future that is free from HIV and AIDS and where preventable maternal deaths are eliminated.