By Mary Stewart Burgher, AWC Denmark
We all love to see happy mothers and their smiling babies, but pregnancy and childbirth are often difficult and dangerous. They have become much safer for women: for example, maternal deaths are now expressed as the number per 100,000 live births – in contrast to newborn deaths, which are expressed as the number per 1,000 live births.
Increases in living standards and improvements in health and health care have reduced the number of maternal deaths, but not enough: the World Health Organization (WHO) estimates that 810 women died during pregnancy or from complications arising from childbirth every day in 2017. And the burden of maternal illness and death falls especially heavily on women who are very young (under age 15), are poor, and/or belong to marginalized groups in society.
FAWCO supports United Nations-led and individual programs to ensure that women who choose pregnancy and childbirth pass through them safely and emerge with healthy babies.
Risks and causes of death
Pregnancy and childbirth can involve a number of risks:
- anemia;
- pregnancy-related high blood pressure, which can lead to pre-eclampsia;
- pre-eclampsia (a condition starting after 20 weeks of pregnancy that causes high blood pressure and problems with the kidneys and other organs – also called toxemia);
- ectopic pregnancy (when a fertilized egg implants outside of the uterus, usually in the fallopian tube);
- gestational diabetes;
- hyperemesis gravidarum (severe, persistent nausea and vomiting during pregnancy — more extreme than “morning sickness”);
- miscarriage;
- placenta previa (placenta covers part or entire opening of cervix inside the uterus);
- placental abruption (placenta separates from uterine wall before delivery);
- preterm labor (before 37 weeks of pregnancy).
And WHO attributes 75% of pregnancy- and childbirth-related deaths to:
- severe bleeding (hemorrhage – mostly bleeding after childbirth);
- infections (usually after childbirth);
- high blood pressure during pregnancy (pre-eclampsia and eclampsia);
- complications from delivery;
- unsafe abortion.
Good news and bad news
The good news is that most maternal deaths can be prevented by good care before and during childbirth. The bad news is that poor countries struggle to provide such care, and poor women in rich countries sometimes struggle to receive it. WHO says that about 86% of the estimated global maternal deaths in 2017 (254,000) occurred in sub-Saharan Africa and southern Asia.
The UN tackled the bad news through Millennium Development Goal (MDG) 5, whose aims were to reduce maternal mortality by 75% from its 1990 level (380 deaths per 100,000) and achieve universal access to reproductive health services by 2015.
The results? Again, good news and bad news. The bad news is that the world did not achieve the desired 75% cut in maternal deaths. But it did achieve a very great deal: a steep decline in maternal deaths and a smaller increase in access to antenatal care (the best way to identify problems early and thus reduce maternal deaths).
Some of the achievements of MDG 5 include:
- a 45% reduction in the maternal death rate worldwide, including reductions of 64% in southern Asia and 49% in sub-Saharan Africa;
- a 12% increase in the number of births assisted by skilled health personnel globally in 2014 compared to 1990: from 59% to 71%;
- an increase in the proportion of pregnant women receiving four or more antenatal visits in North Africa from 50% in 1990 to 89% in 2014;
- an increase in contraceptive use among women aged 15–49 years old, from 55 to 64% between 1990 and 2015.
Trying harder
But the world did not rest on its laurels: countries adopted the 17 Sustainable Development Goals (SDGs), including a new, ambitious goal for reducing maternal deaths in SDG 3, which aims to promote health for all people, at all ages. SDG target 3.1 aims “By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births.”
While most of the world – even the poorest countries with the highest death rates – was reducing maternal mortality, rates of maternal death rose in one of the world’s most highly developed countries – the United States of America. As NPR described it: “U.S. Has The Worst Rate Of Maternal Deaths In The Developed World”: 26.4 per 100,000 in 2015, versus 3.8–9.2 per 100,000 in 12 western European countries and Australia.
A WHO journal identified three factors probably contributing to the upward trend in maternal mortality and morbidity in the USA:
- inconsistent obstetric practice to manage obstetric emergencies and the complications of pregnancy and childbirth;
- the increasing number of women who come to antenatal clinics with chronic conditions, such as hypertension, diabetes and obesity, which contribute to pregnancy-related complications;
- the general lack of good data – and related analysis – on maternal health outcomes.
But there was good news, too:
There is a growing effort by physicians, nurses, and community organizations to address these three factors. Hospitals are beginning to implement standard approaches to managing obstetric emergencies so that wherever a woman gives birth, she receives appropriate evidence-based care. Community initiatives are coordinating care for high-risk women to ensure good health and management of chronic conditions during and beyond pregnancy. More states are establishing or strengthening maternal mortality review boards.
One example of this good news is the California Maternal Quality Care Collaborative, founded in 2006 to study all maternal deaths to find their causes and ways to prevent them. It developed protocols and toolkits to be carried out by teams of health workers to handle childbirth emergencies, and they worked! From 2006 to 2013, the maternal death rate in California fell by over half: 55%. The protocols have not only saved women from dying, but have also dramatically reduced the rate of women who nearly died: a 21% fall in the rate of severe maternal illness due to hemorrhage.
Continuing to study maternal illness and death, however, the Centers for Disease Control and Prevention (CDC) documented a further important discovery: that racial and ethnic disparities continue in pregnancy-related deaths in the United States. Black, American Indian and Alaska Native women are 2–3 times more likely to die from pregnancy-related causes than white women. The disparity increased with age but, importantly, does not vary according to education level. For example, the pregnancy-related mortality rate for black women with at least a college degree was 5.2 times that of their white counterparts. Disparities did not change significantly between 2007–2008 and 2015–2016.
As a response, the CDC urged hospitals and health care systems to:
- Implement standardized protocols in quality improvement initiatives, especially among facilities that serve disproportionately affected communities.
- Identify and address implicit bias in healthcare that would likely improve patient-provider interactions, health communication, and health outcomes.
And the CDC pledged to support state and local maternal mortality review committees to further identify priority strategies that would reduce disparities in pregnancy-related mortality.
Last good news
Most pregnancy- and childbirth-related deaths can be prevented, and most of the world has not only taken great strides towards doing so but also continues the struggle. But there’s much work to do, even in the richest countries, before the goal is reached.
We must all try harder!
Sources:
https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/pregnancy-complications
https://www.mdgmonitor.org/mdg-5-improve-maternal-health
https://www.who.int/sdg/targets/en/
https://www.npr.org/2017/05/12/528098789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed-world?t=1569164705812
https://www.who.int/bulletin/volumes/93/3/14-148627/en/
https://www.cmqcc.org/who-we-are
https://www.cdc.gov/media/releases/2019/p0905-racial-ethnic-disparities-pregnancy-deaths.html