Working for mother and child

Just out of college, Deborah Maine got a dream job for someone interested in anthropology—she worked for Margaret Mead at the American Museum of Natural History in New York. “But soon,” she says, “I wanted something more action-oriented.” With that goal in mind, she went back to school to get an M.P.H. and later earned a doctorate in public health. Setting to work, her focus in international public health was women’s health. From 1987 to 2005 she directed two programs on maternal mortality at Columbia University that have made significant improvements in maternal health care in the developing world.

In June 2005 Maine joined the School of Public Health as a professor of international health and a member of the Center for International Health and Development (CIHD), teaching reproductive health classes and starting the next phase of her work.

“Deborah is recognized as a world leader in thinking creatively about some of the crucial issues facing the reproductive health agenda,” says Associate Professor Jonathon Simon, chair of the Department of International Health and CIHD director.

“She has proven herself over the last twenty years to be an innovator, somebody willing to take thoughtful, alternative positions. She’s well trained in epidemiology, and therefore she wants to bring an evidence base to the study and practice of reproductive health, and for all those reasons, she helps us try to strengthen our program in this area.”

Maine hopes to build a strong teaching and research program on reproductive health in developing countries. “Reproductive health conditions account for a large proportion of the global burden of disease—more than one-quarter of the burden for women and infants in developing countries. During my career, I have worked intensively on several aspects of reproductive health, especially family planning and maternal survival,” she says. “There is a wealth of expertise in the Boston area on reproductive health, but no strong academic program that draws on that expertise. I would like to see BUSPH become an academic center of excellence in this field, working with other institutions in the U.S. and around the world.”

She’s long been interested in that point where evidence and policy meet—or don’t. One of those areas in the mid-1980s was international maternal and child health (MCH) programs. “When I looked at maternal mortality, it was clear what women died of—the same things they died of in the 1600s—hemorrhage, infection, obstructive labor. And when you looked at maternal and child health programs, you saw they did nothing about the things that killed women.”

She and Allan Rosenfield, dean of Columbia’s Mailman School of Public Health, published an article in Lancet in 1985—“Where’s the M in MCH?”—that took the international health field to task for this deficiency and sparked a new phase in maternal health programs in the developing world.

With funding from the Carnegie Foundation, she directed Columbia University’s Prevention of Maternal Mortality program. It provided technical support to a network of eleven multidisciplinary teams in West Africa from 1987 to 1996. The typical project would be for a team in, say, northern Sierra Leone to go to a district hospital, find out why a maternal health program wasn’t working and what needed to be fixed. “Once the hospital was functioning better, they’d move out to health centers and the community. There were lots of great community activities, but not until the health services were working,” Maine says.

After ten years, the result was a greater focus on maternal health care, but it wasn’t enough for Maine. By then “it was clear that many agencies really didn’t want to deal with the health system.” They were comfortable working on community projects, but working to improve health centers and rural hospitals was seen as very difficult.  Moreover, Maine says, there was an assumption that life-threatening obstetric complications can mostly be prevented or predicted, which is not true. Women in the U.S. develop complications, but they don’t die, because they get good, prompt medical care. Thus, preventing a maternal death requires good emergency medical care.

Maine and her colleagues at Columbia decided to confront the problem head-on. With a large grant from the Gates Foundation, they devised a program to directly address poorly functioning emergency health services in hospitals. Gates provided $56 million from 1999 through 2005 and recently awarded $10 million for the second phase of the program.

Maine thought the project would work better if run by field agencies on the ground. “The world did not need Columbia University projects; it needed the whole ship to be turned. I realized that the thing to do was to involve big agencies like UNICEF and CARE, which already had field offices and were going to be there for a long time, but didn’t necessarily do much with health facilities,” Maine says.

“We went to these agencies and said we were going to focus on emergency obstetric care,” she says. “There would be activities in the communities as well, but that was the core of what we wanted to do.” Maine, who directed the Averting Maternal Death and Disability (AMDD) program, says the agencies were invited to design their own projects, and in the end, the eighteen biggest projects covered a population of 179 million people. Within two or three years in these project sites, the capacity to provide emergency obstetric care doubled.

Improving maternal mortality rates is often a management issue, Maine says. “So often we’d go to a hospital and they’d say, ‘We could do a C-section, but the light is broken over the operating table.’ So really, for want of some small things, lives were being lost.” The solution was to address “things like maintenance, clinical supervision, problem solving at the facility, and awareness on the part of the local ministry.”

The Gates Foundation asked a team of experts to evaluate the program, and they reported in 2004 that AMDD “helped to fill a significant gap in global programming for maternal health. AMDD’s technical, programmatic, and financial assistance to implementing partners has greatly improved the quality and effectiveness of maternal health services. The worldwide scale of the AMDD project is unprecedented among safe motherhood programs.”

Now at BUSPH, Maine is still spending about 30 percent of her time as a senior technical advisor to AMDD and is teaching a class on reproductive health. “She’s got the challenge to further strengthen our course offerings and our teaching in this area and to develop an applied research program that complements that teaching and contributes to the global knowledge base on reproductive health issues,” says Simon.

“I’m looking forward to continuing the maternal reproductive work, but also building up some new activities here,” Maine says, pointing to the area of reproductive health screening, which she says is often misapplied. “The gap between the evidence and the programs is what gives me the energy to focus intensively on something.”

This article was published in the Spring 2006 issue of health sphere, the magazine of the School of Public Health.