Most girls grow up wanting to be mothers, of bearing and nurturing life. But for many millions of women, the process of pregnancy and the postpartum period can turn deadly for both mother and child. According to the WHO, around 800 women die every day due to complications in pregnancy and childbirth.
The major complications that account for almost 75% of all maternal deaths are severe bleeding, infections (usually after childbirth), high blood pressure during pregnancy (pre-eclampsia and eclampsia), complications from delivery and unsafe abortion. What makes the situation worse is that most of these causes are avoidable or treatable with proper care, education and processes in place. Timely management and treatment can make the difference between life and death.
The main goals of the UN Millennium Development Goal 5–Maternal Health is to reduce the maternal mortality ratio by at least three quarters, and to achieve universal access to reproductive health by 2015. According to the UN, maternal health encompasses the health of women during pregnancy, childbirth and the postpartum period. It includes in its purview elements of family planning, preconception, prenatal and postnatal care.
Where we stand now
In the past 23 years, we have made some progress in providing safer, less lethal conditions and options available to expectant and new mothers. Between 1990 and 2013, the worldwide maternity mortality rate fell almost 45% from 523,000 deaths in 1990 to 289,000 deaths in 2013. This is still far from the UN Millennium Development Goal of a 75% drop, and accelerated interventions are required in order to meet the target by 2015. That translates to a drop to 131,000 deaths by 2015. A Herculean task, certainly, but not impossible.
Some of the large increases we saw in the use of contraceptives in the 1990s have not sustained into the 2000s and Official Development Assistance for family planning and reproductive health remains low. A tough issue to combat is the increasing use of sterilisation as a mandate in countries like India in an effort to reduce population growth rates. Unhygienic conditions under which these operations are performed (in some areas, up to hundreds in a day) sometimes result in death, or in other health complications.
Where is the world is this happening? Does geography matter?
To put it plainly, yes.
Where in Europe the chance of dying due to pregnancy related complications is 1 in 3300, in Africa, this ratio shoots to 1 in 40. Sub Saharan Africa is touted to be the most dangerous place for a woman to have a baby in the world, with Nigeria alone registering 40,000 deaths in 2013.
This is lesser than the total number of pregnancy related deaths in India which stood at 50,000. Together, these two countries comprise of one third of total global deaths.Developed vs Developing countries- a larger population resides in developing countries than in developed countries, and these countries often experience higher population growth rates, as well as higher pregnancy rates. The maternal mortality ratio in developing countries is 230 per 100,000 live births versus 16 per 100,000 live births in developed countries, with some countries exhibiting rates of up to 1000 deaths per 100,00 live births.
Other factors affecting the mortality rates are income levels and whether or not or not women live in an urban area, where advanced care is more accessible. Of course, lack of information on female reproductive health and cultural practices play a strong role in determining the conditions under which a woman goes through the journey of pregnancy.
What about age?
Adolescent girls under 15 years of age are at the highest risk of maternal mortality. More than 95% of adolescent pregnancies occur in developing countries and the risks of adolescent pregnancies extend fairly viciously to the mother as well as the child. The chance of a stillbirth or death within a month of being born increases by more than 50% in women under the age of 20, and the rates of preterm birth low birth weight and asphyxia are higher. Half of all adolescent births occur in Bangladesh, Brazil, Congo, Ethiopia, India, Nigeria and the US.
Adolescent pregnancies also have an adverse effect on communities are girls are forced to leave school, assume responsibilities at a younger age, and fend for themselves and their child if their community does not support them. While having children out of wedlock is not a particular cause for concern in Latin American and Caribbean countries, in conservative countries like India and Bangladesh, having a child outside wedlock usually leaves the girl or woman a social pariah.
Newborn health is closely related to maternal health. Almost 3 million newborn babies die every year, and some 2.6 million babies are stillborn.
So..what can we do about this?
A very important infographic from WHO lists that the five most important steps to saving more lives are:
- Quality care before, during and after childbirth- This includes timely diagnosis of the pregnancy itself, as well as of other conditions that might affect the health of a pregnant woman, including pre eclampsia.
- Safe blood supplies- In South and Southeast Asia and Africa, areas which are rife with HIV infected people, it is important to ensure safe blood supplies to prevent the spread of infection. Safe supplies are especially important in cases where severe blood loss is encountered after childbirth.
- Essential medicines such as antibiotics and oxytocin- Injecting oxytocin immediately after childbirth significantly reduces the risk of bleeding, and drugs like magnesium sulfate for pre-eclampsia can lower a woman’s risk of developing eclampsia.
- Contraception and safe abortion services- Unwanted pregnancies result in rash decisions by women to risk their life in an unsafe abortion attempt, and in countries like India, forced sterilisation has proven to harm reproductive health, and in some cases, cause death.
- Count and record of every death- Statistics are important in gauging the success (or failure) of the initiatives taken, and lessons learned from one death may help save someone else.
In addition, education on female reproductive health, training of healthcare personnel, continuous monitoring of the situation as well as free access to contraceptives, medicines and feminine hygiene products is equally important. This eliminates the risk of life threatening infections. The more women (and men too) are made aware of their sexual health, of their legal right to abortion, of feminine hygiene, the less stressful this journey will seem.
Legal rights for women, such as compulsory paid leave of absence for at least three months after giving birth, or bilateral agreements on training and access to medicines related to maternal health are some of the other measures that would ensure a secure environment for the new mother. This would be especially beneficial in developing countries where women are often equally important in contributing to household finances, and a pregnancy hampers their finances adversely. Finally, family planning within communities and with professionals might help remove the stigma of abortion of an unwanted child, which leads to large, unsustainable families.
Looking Ahead- The Race to 2015
Many countries like Bangladesh and Eritrea are taking proactive steps in reducing national maternal and infant mortality rates, especially by training midwives and other healthcare personnel.
Only 32% of Bangladeshi women are looked after a skilled attendant while giving birth, and for every 100,000 live births, 170 women still die. To remedy this situation, the Government of Bangladesh with technical and financial support from the WHO and UN Population Fund (UNFPA), is aiming to train 300 midwives by 2015. The strategy involves a 6 month advanced midwifery certificate, a 3 year direct entry diploma in midwifery and training to ensure midwives qualified to teach both the courses. Till date, more than 1100 students have graduated from the certificate programme, and more than 1200 students are enrolled in the diploma course, with the first group graduating in 2015.
In Eritrea, the combined efforts of the government, UNICEF, WHO, UNFPA and UNDP in increasing awareness of maternal health issues in the country, and training sessions in rural areas has led to each community in Eritrea now boasting of fully trained maternal caregivers, putting Eritrea on the track to achieving MDG 5. From a country that had 1400 deaths per 100,000 live births, Eritrea is on it’s way to attaining a rate of less than 350 deaths per 100,00 live births.
In 2010, with only five years left to achieve the MDGs, UN Secretary General Ban Ki Moon launched the Global Strategy for Women’s and Children’s Health (1), which initiated the Every Woman Every Child (EWEC) movement to accelerate progress on MDGs 4 (Reducing child mortality) and 5. H4+ is an initiative of collective leadership and a collaborative effort by six agencies within the United Nations system (UNAIDS, UNFPA, UNICEF, UN Women, WHO and the World Bank) to provide harmonized support to countries, especially those with a high burden of maternal and child mortality. In September 2014, a progress report of 58 countries with regard to quantitative and qualitative data was released to gauge the effectiveness of the implementation of this programme. At the country level, with the support of the H4+ partnership, countries have carried out educational campaigns, created and strengthened curricula for training programmes, helped improve procurement and supply management systems for medicines and other vital commodities, and improved monitoring and evaluation systems for surveillance of the status of women’s and children’s health.
To highlight this pressing issue, the WHO is also making use of innovative ideas such as the ‘Saving Lives at Birth’ Challenge to invite the public to find ways to reduce maternal mortality rate. In addition, the organisation is promoting the use of technology to provide updates on best practices, automated reminders, reporting, support and counselling through the use of the OpenSRP Platform. Other highlights include developing centres of excellence in Knowledge Transition in maternal and perinatal health, ending disrespect and abuse during childbirth and improving accessibility of life saving drugs.
Maternal Death Surveillance and Response (MDSR) builds on the principles of public health surveillance, promotes routine identification and timely notification of maternal deaths and is a form of continuous surveillance linking health information system and quality improvement processes from local to national level. Its primary goal is to eliminate preventable maternal mortality by obtaining and strategically using information to guide public health actions and monitoring their impact. This includes monitoring and reviewing each case. This system has not replaced the current Maternal Death Reviews (MDR) system in place because of concerns that the increasing demand for accountability will reduce confidentiality.
With or without the MDSR, there is a call to increase the reporting of every case of maternal death, as well as severe morbidity cases. Another call for action is to involve individuals, families and whole communities in educating themselves about maternal health. Finally, proper training of midwives and other personnel is important in saving the lives of both mothers and their newborns, and to look into innovative strategies to increase the scope of the same.
Maternal Health is as much an international problem as it is a regional one. Women form half of the world’s population, and a more than a sizable part of the workforce, in both rural and urban areas. Mothers are highly respected throughout the world, and we owe future mothers the right, not the privilege, of a safe and healthy pregnancy and childbirth experience.
This article is part of the UNYANET Millennium Development Goals blog series.