The United Nations has been loudly broadcasting the good news in the last few years about the overall reduction in maternal mortality globally, but what it has not vocalized as well is that the gap doubled between countries with the lowest and highest rates of maternal deaths from 1990 to 2013.
That gap continues to stymie advocates for improving maternal health worldwide, who describe two main areas thwarting progress: the well-known problem of helping women “too little, too late” in poor countries; and, less well known but equally challenging, the problem of instituting “too much, too soon.” That is, the overmedicalization of childbirth in both rich and, increasingly, lower- to middle-income countries, resulting in interventions that are both unnecessary and costly.
These interventions range from unnecessary ultrasounds and labor inductions and augmentation to, once in labor, continuous electronic fetal monitoring and other procedures that may lead to unnecessary Caesarean sections. Even for those who give birth vaginally, routine episiotomies may cause perineal lacerations and a more difficult postpartum recovery.
While these problems are more commonly associated with hospital deliveries in wealthier countries, the C-section rate in lower- and middle-income countries is also soaring, as is the unnecessary use of antibiotics during labor as a substitute for proper hygiene.
Efforts to improve maternal health worldwide dovetail with a set of 17 global priorities approved in 2015 by member states of the United Nations to be implemented by 2030. Building on the eight Millennium Development Goals adopted in 2000 to complete what was not attained, the SDGs, or sustainable development goals, tackle everything from human health and rights to peace and security, the environment and reducing economic inequalities.
One goal specifically calls for the number of maternal deaths worldwide to be reduced to fewer than 70 per 100,000 women, following the unachieved Millennium Development Goal of reducing the maternal mortality ratio by 75 percent between 1990 and 2015. While much progress has been made — the rate has been reduced nearly by half since 1990 — obstacles remain.
A series on maternal health published by The Lancet in September articulated the well-studied problem of helping women “too little, too late” in poorer countries and described the complications that may occur when women in wealthier countries are subject to unnecessary interventions. The series also found that approximately one-quarter of newborns worldwide are delivered without a skilled birth attendant, and that while more mothers are using a birth facility, the quality of care varies.
“Of course, the progress is very patchy,” an author of the series, Wendy Graham, told PassBlue in an interview. Graham is a professor of obstetric epidemiology at the London School of Hygiene and Tropical Medicine, emeritus professor at the University of Aberdeen and chief scientific adviser for the Soapbox Collaborative, a British-based charity that promotes safe, clean births in poor countries. Noting that 53 million women deliver babies each year without a skilled attendant present, she said, “You’ve got this very parallel universe” of “too much, too soon” and “too little, too late.”
Suellen Miller, a midwife, international maternal health expert and an author of the Lancet study, said, “It just seems that there are these extremes.” With medical interventions taking place despite the lack of evidence supporting their use, she added, “people are trying to not let nature take its course.”
Dr. Anthony Costello, who heads the Department of Maternal, Newborn, Child and Adolescent Health at the World Health Organization, welcomed the Lancet’s new series, noting that while the data summary shows a downward trend of maternal deaths, the actual number is only an estimate.
“Most poor countries do not record systematic maternal deaths,” but use a system of guesswork and surveys, Dr. Costello said. The rate may also not reflect deaths from unsafe abortions, suicide and indirect causes, such as malaria and HIV, he added. “Although there is no doubt” there is a decreasing trend in the rate, “there still is a long way to go.”
Observing the many delays that can prevent a woman in labor from receiving proper medical care, from lack of transportation to an understaffed medical center, the issue becomes one of quality of care. Both “too little too late” and “too much too soon” are factors that can come into play, Dr. Costello said, “sometimes both in the same country.”
To address these issues, the WHO published a set of guidelines this year for treating mothers and newborns, “Standards for Improving Quality of Maternal and Newborn Care in Health Facilities.” The guidelines feature eight domains of quality of care that should be assessed, improved and monitored in health care systems. Six strategic areas have been identified for treating women in labor based on sound medical evidence.
In richer countries, the Lancet study found that rates of maternal deaths are decreasing but there is still wide variation at national and international levels. For instance, in the United States, the maternal death ratio is 14 per 100,000 live births, compared with 4 per 100,000 in Sweden. Other challenges in delivering high-quality care include the increasing age of first-time pregnant women and higher rates of obesity.
The authors of the Lancet series, which was financed by the MacArthur Foundation, the Bill & Melinda Gates Foundation and USAID’s Maternal and Child Survival Program, identify five priorities that require immediate attention if the SDG maternal mortality target is to be achieved. These include providing quality maternal-health services that respond to local needs, promoting universal coverage of quality maternal-health services, improving the health care workforce and quality of medical facilities and guaranteeing sustainable financing for maternal and perinatal health.
On the “too much, too soon” front, Caesarean sections remain a major concern, comprising 56.7 percent of births in Brazil, for example, and half of all hospital births in Bangladesh. The Lancet study found that rates are soaring even in middle-income countries like Mexico (46.9 percent), Turkey (48), Egypt (51.8) and the Dominican Republic (58.9).
In the US, the C-section rate in 2015 was 32 percent, according to the Centers for Disease Control and Prevention’s National Center for Health Statistics.
Dr. Costello of the WHO is pro-midwife and supports giving birth at home as long as there is immediate access to emergency care. “It improves the passage of labor,” he said. The hospital setting is more stressful for mothers, which results in more complications, and the care they receive is based on procedures not supported by medical reality, or “a lot of nonevidenced-based procedures.”
Some successful solutions to treat persistent problems in childbirth, specifically post-partum hemorrhage, can be rather low-tech, Suellen Miller of the Lancet study pointed out. Miller is a professor at the University of California at San Francisco’s Department of Obstetrics, Gynecology and Reproductive Sciences and director of the Safe Motherhood Program at the university’s Bixby Center for Global Reproductive Health. In addition, she is the principal investigator of the Life Wrap, also known as the NASG (non-pneumatic antishock garment), a device resembling a wetsuit that is wrapped around the lower half of a woman’s body during labor to stabilize her until emergency care — principally, a blood transfusion — is available.
The device, originally developed by NASA for astronauts, was used in American ambulances for trauma before it fell into disuse in the 1990s, Miller said. She and another American physician, the late Dr. Paul Hensleigh, thought to use it globally for women facing long delays in getting to hospitals and receiving transfusions. A study in Tanzania showed that its use reduced the mortality rate from hemorrhaging by 69 percent, Miller said.
The video below is of a Nigerian woman, Aisha, whose life was saved by the Life Wrap.
The last comprehensive maternal health study issued by the Lancet took place in 2006, according to Graham of the recent Lancet series, and focused mainly on mortality. The new series also highlights pregnancy-related disability, or morbidity. Focusing only on death is the “tip of the iceberg,” she said, pointing to other devastating complications, such as obstetric fistula, a hole that occurs between the vagina and rectum or bladder, caused by prolonged obstructed labor and that leaves a woman incontinent, as well as interventions such as episiotomies.
Women deserve quality care that is “effective, safe and is a good experience,” she said. “This is a 21st-century issue.”
Miller’s Safe Motherhood Program described 30 instances of maternal morbidity with every mortality worldwide. C-section complications include bladder injury or the nicking of the vaginal wall, and the procedure possibly creating “problems for the women that are life threatening,” Miller said.
“The causes of death are shifting,” Graham said, noting that in 2006 hemorrhage and sepsis were major factors. The new Lancet study says that deaths from direct causes, such as pre-eclampsia and eclampsia, have decreased, whereas indirect causes such as cardiovascular disease have gone up.
The global shift to a more urban lifestyle has led to increases in heart attacks, strokes and diabetes, a phenomenon in wealthy as well as middle- and lower-income countries. “More and more people are eating junk food,” Dr. Costello said, noting that even in Bangladesh, 30 percent of younger people have full-blown or pre-diabetes.
Another huge problem in the field is antimicrobial resistance (AMR), which happens when bacteria become resistant to the antibiotics used to treat the infections they cause. This results from their overprescription, overuse in livestock and fish farming, lack of hygiene and poor sanitation and poor infection control in hospitals and clinics, according to the WHO.
“It’s not an area that there has been nearly enough work on,” said Dr. Elizabeth Tayler, senior technical officer in the WHO’s Antimicrobial Resistance Department. “It’s a really interesting messy area.”
“Antibiotics have been a substitute for high-quality care and good hygiene prevention,” she said, noting that the drugs will continue to work only if they remain effective. While much more data is needed, the WHO officially recommends no antibiotics during routine labor.
“What we need to do is improve the hygiene around delivery, and have safe, clean deliveries,” Dr. Tayler said. That is how death rates from infection came down in the US and Europe before the use of antibiotics, she added.
Antimicrobial resistance is another reason to pursue good obstetric and neonatal care and midwifery care. “Most interventions put you at more risk of bacterial infection,” Dr. Tayler said. And while having a C-section in countries like the US is normally safe and hygienic, in facilities with poor hygiene, there is a higher risk of infection.
“The solution, however, is to improve the hygiene and not use the antibiotics,” Dr. Tayler said. “This is not about stopping antibiotics to people who need them.”
Graham concurred, saying, “We must save our antibiotics for those who really need it.”
Dr. Costello also discussed the rapidly rising rates of antimicrobial resistance in hospital maternity units, citing the recently published Delhi Neonatal Infection Study, which found a high incidence of sepsis, one of the most common causes of neonatal deaths, and an alarming degree of antimicrobial resistance among pathogens in babies born in three major hospitals in Delhi. Most sepsis-related deaths occur in low-income and middle-income countries.
“We’re chucking around antibiotics,” Dr. Costello said. “You just generate resistance and then you have a worse problem.”
A continuing problem in promoting maternal health is not just that proper medical procedures or guidelines are lacking, but that carrying them out is hindered by factors on the ground.
“All of these things are always more complicated,” said Lynn Freedman, director of Columbia University’s Mailman School of Public Health’s Averting Maternal Death and Disability Program, which has worked with UN agencies, nongovernment organizations and governments in more than 50 countries to reduce maternal deaths. Despite guidelines from the WHO maintained in each country, “having high-quality, evidence-based clinical and infrastructural guidelines is never enough to ensure that they are followed in practice,” she said.
That is because, Freedman said, “the practice of running a health system and interacting with women and keeping workers well supported and functioning well” is a “deeply social, sometimes highly political process, and that’s why it’s never as simple as [figuring] out the right thing to do and decree or mandate that people will do it.”
Explaining that many different approaches on how to support women’s maternal health are being tried globally, Freedman also said the field, as a whole, has not paid enough attention to what is called “implementation science.”
Which reverts to the “act global, think local” mantra. Freedman, who co-authored a paper, “Act Global, but Think Local: Accountability at the Frontiers,” published by Reproductive Health Matters, said the mantra includes empowering people locally to act and give communities, civil society organizations, women’s groups and consumers “a different kind of power and role in helping to develop the dynamics of accountability in systems.” Such methods include starting village health and hospital committees, issuing health care “report cards” and other transparency initiatives.
“People at the local level need to have some power to change things, but there also needs to be some kinds of checks on that power to ensure that it’s exercised in the interest of people’s rights and needs,” Freedman said. “It’s never one solution.”
Graham agreed that solutions must be found at all levels, from high-echelon UN engagement to working with “big pharma” down to the community level of providers, pharmacists and women on the ground. “It’s got to be a multitiered response.”
Is the SDG goal of less than 70 deaths per 100,000 births reasonable? “The closer people get to that goal, the better it is,” Miller said. People have a “right to survive and right to thrive.”
Dr. Costello said it was certainly possible to achieve the SDG goals, “but I think we have to make a much bigger effort.” That involves funding, of course, but also a commitment to “evidence-based interventions.” Accountability is needed at the village, city and national level. Globally, “you need strong multilateral institutions.”
“I think the WHO rightly receives some criticism over its response” to infections such as Ebola, Dr. Costello added, “but if the world wants a strong and effective World Health Organization, it must invest in it.” He noted that the agency’s budget has been static over the last 10 years, with staff rates cut in the departments of maternal, child and adolescent health.
Graham said the goal of improving maternal health was actually “less visible” with the SDGs than it was as a Millennium Development Goal, in which the maternal piece was more prominent. “Improve maternal health” was one of the eight original goals, while the maternal mortality goal is now subsumed within SDG 3, “Ensure healthy lives and promote well-being for all at all ages.”
“The maternal piece is there, but not explicitly,” Graham said. “We don’t have a dedicated SDG just for maternal health.”
Yet the SDGs also provide an opportunity to make connections with other global goals. “We need to connect the maternal health agenda with the wider agenda,” Graham said, with fertility as “the fundamental starting point.”
“This is about producing the next generation of the world,” she added. “What bigger issue could there be?”