How does maternal mortality become a priority health issue? Shiffman provides case examples in the May 2007 issue of the American Journal of Public Health. He examined policy and program changes in 5 countries: Guatemala, Honduras, India, Indonesia, and Nigeria, and provides a valuable framework for identifying the domestic and international influences and barriers on policy change. The example of Nigeria helps us see how malaria in pregnancy funding and programming might help draw attention to reducing maternal mortality.
Nigeria has the highest maternal mortality rate of the 5 countries (704/100,000 live births), and Shiffman reports that Safe Motherhood is still not receiving the attention it needs in Nigeria. One hopes that the problem of maternal mortality will receives greater attention because of increased malaria program efforts. Participation by Nigeria in the Roll Back Malaria Partnership and its management of malaria grants from the Global Fund have put a spotlight on the contribution of malaria control to safer motherhood. The National Guidelines for Prevention and Control of Malaria During Pregnancy (2005) outline clearly the path from malaria to anemia to maternal mortality and estimate that malaria contributes to 11% of the nation’s maternal mortality rate. The guidelines therefore stress IPTp, ITNs for pregnant women and prompt case management when pregnant women experience an episode of malaria. Likewise the National Reproductive Health Strategic Framework lists malaria among the preventable causes of maternal morbidity and mortality.
Donors are supporting MIP prevention and control activities. IPTp and ITNs are a key component of Nigeria’s Global Fund grant. USAID and the World Bank Booster program are also operating in Nigeria, and both include MIP interventions, particularly nets and IPTp. This level of external support and attention demonstrates “Transnational influences” on policy through norm promotion and resource provision, as explained by Shiffman.
There remain domestic policy challenges to Safe Motherhood in Nigeria. While partners are pulling together to fight malaria, the same cannot be said for Safe Motherhood. A recent MIP strategy workshop in Abuja sponsored by USAID’s ACCESS project and involving both the malaria and reproductive health (RH) program units of the Federal and some State Ministries of Health specifically forged stronger working relationships between the two program areas such that greater attention to malaria may in fact benefit Safe Motherhood. Shiffman emphasized the importance of reaching out to state and local decision makers too, since in Nigeria they make major decisions about allocating resources for public health.
If international malaria partners continue to stress the importance of addressing malaria in pregnancy using all three key control measures as part of a comprehensive malaria strategy, as is done in Nigeria, their efforts will hopefully also have the benefit of making Motherhood Safer.