SUSANNAH WOODD: Pregnancy and childbirth is often considered a natural process and an occasion for joy. However, for far too many women, it can instead be a time of illness, suffering, and sometimes even death. In 2015, the WHO reported that there were 303,000 maternal deaths. Due to the challenges involved in estimating maternal mortality, there is considerable uncertainty surrounding this figure. But we are confident that there is significant improvement from 25 years earlier. However, the number is still shockingly high, considering most maternal deaths are avoidable, and many of those dying were previously healthy young women. But while mortality remains incredibly important, it is only a small part of the picture.
We estimate that each year, 2 million pregnant women suffer a near miss complication, and 27 million episodes of illness occur, related to the five main direct causes of death. Even greater numbers suffer from other important health problems such as heart disease or depression. Around a fifth of women delivering will undergo surgery for Caesarean section. And the vast majority will suffer minor complaints such as vomiting and heartburn. In addition. Illness in pregnancy and the process of childbirth can lead to long-term disabling complications such as vaginal fistula. So a lot of work is still needed to improve maternal health.
The sustainable development goals have set ambitious targets to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. Now in 2015, the ratio was 216 per 100,000. In addition, every country has two targets– a reduction in MMR of two thirds from 2010 to 2030, and an overall ratio of less than 140 per 100,000 by 2030. Is this possible? Well in the 50 countries with the highest MMR, the annual rate of reduction in the 25 years up to 2015 was 3.3%. To achieve these SDG targets, this rate needs to double. So there’s a big challenge ahead.
To rise to this challenge, we need to understand more about the where, when, why and who of maternal mortality and morbidity. The global estimated figure of 303,000 deaths hides huge disparities. The vast majority of these deaths, 99%, occur in low and middle income countries. Sub-Saharan Africa accounts for two thirds of the deaths. And just two countries, Nigeria and India, together contribute over one third of all maternal mortality, due in part to their large populations and also the high MMR. In Nigeria it is over 800 per 100,000. There are many reasons why women die, but direct obstetric causes remain the most important, globally. Haemorrhage alone leads to over a quarter of all deaths.
And hypertensive disorders and sepsis and complications of abortion account for another third. These direct complications mainly occur during delivery in the first 24 hours after childbirth as this data from Bangladesh clearly demonstrates. And they can kill fast. A woman can die from Haemorrhage within a couple of hours. But the picture is changing. Increasing urbanisation, wealth, and education, as well as changes in the demographics of pregnant women themselves results in what is described as the obstetric transition, leading to reduced fertility, fewer overall deaths, but at the same time, a lower proportion of deaths from direct obstetric causes such as Haemorrhage and a proportionate increase in indirect mortality such as heart disease, diabetes, influenza.
However, this has happened at different rates in different regions as illustrated here. There is still very little reduction in the importance of Haemorrhage in sub-Saharan Africa, while the proportion dying from indirect causes has substantially increased in high income countries and Latin America, but far less in other regions. Cardiovascular disease, for example, is now the single largest cause of maternal death in the United Kingdom, Australia and the United States. And it is very likely that the obstetric transition just described will drive up the indirect causes of mortality and certainly morbidity elsewhere. Indeed, when we consider maternal morbidity, a far more complex picture emerges. The WHO has identified 121 diagnostic categories of maternal morbidity.
In other words, there’s a huge breadth to the burden. But in addition, the pattern of these conditions is different to that seen with mortality. So postpartum Haemorrhage is important, affecting over 10% of women. But it is possible that a greater proportion suffer from gestational diabetes, a condition that requires careful management throughout pregnancy to avoid poor outcomes such as stillbirth. And there’s a need for ongoing monitoring after birth due to the risk of developing diabetes later in life. Similarly, depression is estimated to affect up to 60% of women. It can occur throughout pregnancy and postpartum– impacts not only on the woman’s health, but also her ability to care for her baby. Now, certain women are more at risk than others.
Maternal mortality is highest in women over 30 years of age, and this is true for countries with a high or low MMR. Age is also a risk factor for common morbidities, such as gestational diabetes and cardiac disease. And women are increasingly giving birth that older ages, so require extra care to manage the increased risk. Women are also at increased risk if they have less access to health services. Within countries, coverage of important maternal health services, such as antenatal visits and delivery with a skilled birth attendant show clear gaps according to wealth, education, geography, and ethnicity. For example, in many Latin American countries, delivery with a skilled attendant is over 20% lower among indigenous compared to non-indigenous women.
The greatest inequality is seen in wealth. In Nigeria, only 6% of the poorest women deliver with a skilled attendant, compared to 85% of the richest. Greater overall coverage is contingent on reducing these gaps, and both are supported by a climate of political stability and good governance. But coverage is still only half the picture. To achieve better health outcomes, the quality of care provided also needs to improve. So in summary, the majority of maternal deaths occur in low- and middle-income countries from direct obstetric causes occurring around the time of birth.
If we are to achieve the SDG targets, we need to amplify efforts to provide good quality delivery care to all women in particular by addressing the wide inequalities that exist within some countries. But at the same time, we must broaden our vision to encompass the prevention and management of the large diverse and potentially growing burden of morbidity. For this to occur, a narrow focus on delivery cab will not be enough. And we must think more creatively and work collaboratively with local providers and with women themselves to drive improvements in all aspects of maternal health.