Target 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births
In 2017, 295,000 women worldwide died during and following pregnancy and childbirth, which equates to approximately 810 women dying every day. This is an startling number, considering most causes of maternal death can be addressed medically. But when it comes to decreasing the burden of deaths and disability caused by giving birth, simply having medical interventions developed is not enough. In most cases, there are other social factors that limit the delivery and efficiency of existing treatments. One of them is limited access to health care.
Source: World Health Organization
Maternal mortality ratio refers to the number of maternal deaths during a given time period per 100,000 live births during the same time period.
Maternal Health refers to the health of women during pregnancy, childbirth and the postnatal period.
Causes of maternal mortality and corresponding interventions
According to a WHO report on maternal health, the top causes of maternal deaths include severe bleeding (postpartum hemorrhage), infection, seizure during childbirth caused by high blood pressure during pregnancy (eclampsia), unsuccessful exit of a baby due to physical blocks (obstructed labor), unsafe abortion and other direct and indirect causes.
Causes of maternal death. *Total is more than 100% due to rounding.
Source: World Health Organization, The World Health Report 2005: Make Every Mother and Child Count, Geneva, 2005.
Some of these risk factors, such as severe bleeding and eclampsia, can be treated with simple medical interventions. Severe bleeding, or postpartum hemorrhage (PPH), is caused by four main reasons: the uterus failing to contract after delivery (uterine atony), all or part of the placenta remain in the uterus during the final stage of labor (retained placenta), the uterus ruptures during labor and deep cuts appearing (lacerations).
Although PPH is hard to prevent as it can happen to any woman during any delivery, it can be managed. For example, uterotonic drugs can help the uterus contract after labor, squeezing potential bleeding points in the uterus and thus closing the “leaks” to prevent bleeding. Other causes can be managed by controlling the traction of the cord that attaches a mother and her baby (umbilical cord) and massaging the uterus after the placenta comes out.
Another example is the management of eclampsia. Although it can lead to conditions that sound scary and complicated, such as seizure and coma, it can be prevented and treated with simple injections of one medication: magnesium sulfate (MgSO4).
Infections can be managed by having a clean environment and providing medications. When mothers give birth to babies, disinfected tools and proper sanitation can prevent infections to the wounds. And even if mothers experience infections, the use of antibiotics can prevent further severe complications.
Preventing deaths caused by unsafe abortion and obstructed labor are more complicated, as both would need skilled health professionals to perform medical procedures. To get a safe abortion, procedures need to be customized according to an individual’s phase of pregancy. The environment in which the procedures are performed need to be sanitized, and trained personnel need to be present to cope with potential complications. One method to cope with obstructed labor is surgically cutting into a mother’s abdomen and uterus to take the baby out directly, instead of squeezing through the birth canal (C-section) when it is physically hard. If these procedures are carried out in unsanitary conditions by untrained people, mothers will face larger health risks, contributing to a higher mortality rate.
WHO Infographic: Prevent unsafe abortion
Source: World Health Organization
The bigger challenge: access to care
It seems that some of the top causes are not hard to prevent or treat medically. But why are they still the leading causes of maternal deaths?
Examining the medical ways to manage the causes of maternal death, words such as “medication,” “treatment” and “interventions” would pop up. These words all appear in one common setting: medical care. Trained health care personnel with medical resources can provide patients with the medications they need, give them proper treatment, and perform interventions when the patients experience dangers during labor. But what if trained care-givers are not present when mothers are giving labor? What if they don’t have the life-saving medications to treat the problems, even if they know what they could do? This indicates the existence of a bigger challenge: access to health care.
Source: Severine Sajous/MSF, Midwife using natural methods to facilitate the patient’s delivery. Lebanon.
To evaluate a population’s access to health care, or access to obstetric care, we can examine the percentage of births attended by skilled health staff. If more births are attended by skilled health care providers, it means that women are more likely to get the care they need if they encounter any danger during labor. A joint statement by WHO, ICM and FIGO shows that approximately 16–33% of maternal deaths can be averted if supervised by a skilled professional. This indicates that having access to proper care during delivery can effectively decrease deaths.
According to the World Bank, North America and Europe & Central Asia have the highest coverage of obstetric care, with nearly 100% of births attended (98.994% in North America and 98.795% in Europe & Central Asia). On the other end of the spectrum, the percentage of births attended in Sub-Saharan Africa countries is only about 60%, significantly lower compared to other regions.
Source: The World Bank
In addition to geographic inequalities, income also plays a role in access to obstetric care. Data from the World Bank in 2016 shows that only around 60% of low income countries have births attended by skilled providers, while the figure rises to about 100% in high income countries.
Source: The World Bank
Even within countries, disparities caused by income exist. In Nigeria, only 5.7% of women from the poorest quintile only have skilled birth attendance, while the number is 85.3% for the richest quintile. According to research done in Kenya, women who reported having enough money prepared for delivery were 4.34 times more likely to seek skilled attendance. The direct results of economic inequalities might be shown in whether women and their families could afford care and transportation to health care services. Economic status can also impact a family’s decision on whether to spend money on health care or not. But this disparity can also contribute to other inequalities, further limiting access to care. For example, the low-income group could have less access to education and information, making it hard for them to understand the necessity of having skilled birth attendants or know when and how to seek help. In poorer regions, infrastructure such as health facilities, road and transportation methods can all be limited compared to richer regions, making access more challenging.
Although challenges exist, there are solutions. One cost-effective solution is to train community health workers. As the name suggests, community health workers come from and are based in their local communities. They are usually trained to provide basic care for a year or two before practicing medicine in their regions. Since the workers are local, they are familiar with both the culture and common health threats in the regions. These understandings of the local context provide them with unique advantages when it comes to communicating suggested health measures and offering culturally-appropriate care to the people in need, resulting in better overall well-being of the population. In addition, since community health workers serve their own regions, some very remote, the geographical barriers of access to care can be removed to some extent, increasing residents’ access to health services, promoting health in the region.
Large numbers of maternal deaths can be prevented because the causes can be treated with modern medical interventions. Yet the bigger problem lies within access to health care, as many women are unable to get the care they need. Therefore, to truly lower maternal mortality ratio and to achieve the SDGs, it is important to address non-medical challenges as well, and more efforts should be focused on improving health access.
About the author
Yuxuan Liu is a journalist/columnist at the Writing and Interview Program of Social Responsibility Practitioners. She is a rising junior studying Global Health who loves mint and chocolate chips ice cream.