HIV and maternal mortality: turning the tide.

The two top causes of death in women of reproductive age globally are HIV/AIDS and complications related to pregnancy and childbearing, which account for 19% and 15% of all deaths in women aged 15–44 years, respectively. The growing burden of HIV infection in young sexually active women and the maternal health problems that they face have been described as two intersecting epidemics. In settings with a high HIV burden and high maternal mortality ratios, especially in sub-Saharan Africa, many HIV-infected pregnant women are confronted not only with the risk of death associated with advancing HIV disease, but also with an increased risk of pregnancy-related death. The relative risk of pregnancy-related death in women infected with HIV compared with that in non-infected women ranges from just over double in one hospital-based study in South Africa to about 13 in a study of women having caesarean deliveries in the USA. Although these studies varied in size and quality, usually including 100 or fewer maternal deaths, there is compelling evidence of increased risk of maternal death in women infected with HIV from nationwide confi dential inquiries into facility-based deaths in pregnant women in South Africa. These inquiries, which have been done since 1997, have shown a steady increase in the number of maternal deaths over time. Although part of the increase is attributable to improved reporting, there are also real increases in deaths associated with rising rates of HIV infection in pregnant women. Between 2005 and 2007, the facility-based maternal mortality ratio in South Africa was nearly ten times higher in women known to be HIV-positive than in women known to be HIV-negative (328/100 000 livebirths compared with 34/100 000 livebirths). Understanding the dimensions and pathways of the increased risk of death in pregnant women with HIV infection is constrained by incomplete and inaccurate data on numbers and causes of maternal deaths. Moreover, unanswered questions about the biological interactions between HIV infection and pregnancy 3 Consensus for Maternal, Newborn and Child Health. http://www.who. int/pmnch/events/2009/20090922_consensus.pdf (accessed May 10, 2010). 4 G8 Leaders Declaration. Responsible leadership for a sustainable future. Para 122. http://www.g8italia2009.it/static/G8_Allegato/G8_ Declaration_08_07_09_fi nal,0.pdf (accessed May 10, 2010). 5 Commission on Macroeconomics and Health. Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health; Dec 20, 2001. http:// www.emro.who.int/cbi/pdf/CMHReportHQ.pdf (accessed May 26, 2010). 6 Cometto G, Ooms G, Starrs A, Zeitz P. A global fund for the health MDGs? Lancet 2009; 373: 1500–02. 7 High Level Taskforce on Innovative International Financing for Health Systems. More money for health, and more health for the money. http:// www.internationalhealthpartnership.net//CMS_fi les/documents/ taskforce_report_EN.pdf (accessed May 10, 2010). 8 Exploring options for optimizing synergies with maternal and child health: decision point GF/B21/DP20. April 30, 2010. http://www.theglobalfund. org/documents/board/21/GF-BM21-DecisionPoints_en.pdf (accessed May 10, 2010). 9 WHO. Maximising positive synergies between health systems and global health initiatives. 2008. http://www.who.int/healthsystems/ MaximizingPositiveSynergies.pdf (accessed May 10, 2010). 10 Sankore R. A call for a massive paradigm shift from just health fi nancing to integrated health, population and social development investment in Africa: the case for progressing from only 15% to 15% plus. Health Financing Paper for AU July 2010 Summit preparatory meeting, Addis Ababa; April 21, 2010. http://www.equinetafrica.org/bibl/docs/ SANfi n23052010.pdf (accessed May 26, 2010). 11 ASADI. Science in action: saving the lives of Africa’s mothers, newborns and children. 2009. http://www.who.int/pmnch/topics/continuum/2009_ scienceinaction/en/index.html (accessed May 10, 2010).