Source: The Guardian
The number of women dying from causes related to pregnancy and childbirth has almost halved since 1990, a global report has revealed.
Worldwide the annual number of maternal deaths per 100,000 live births fell by 44% between 1990 and 2015, from approximately 385 to 216.
The report also highlights that global inequalities in maternal healthcare are increasing, with the gap between countries with the lowest level of maternal deaths and the highest doubling between 1990 and 2013, reaching a 200-fold difference.
“Lots of people worked very hard and progress was achieved, but it was patchy,” said Wendy Graham from the London School of Hygiene and Tropical Medicine, who was a co-coordinator of the report. “Like many things in health, in the progress that the average receives invariably there are some left behind.”
It is estimated that 210 million women become pregnant every year, with 140 million babies born. But according to the report – a series of six papers published in the Lancet by an international team of researchers – provision of maternal healthcare worldwide is hugely variable.
“This is about human rights and a lack of standardised care across the world,” said Stephen Kennedy, head of the Nuffield department of obstetrics & gynaecology at the University of Oxford, who was not involved in the series.
“Women should be as healthy as possible before pregnancy and have access to adequate health care when they are pregnant,” he added. “There is then no reason why common problems in pregnancy shouldn’t be managed in exactly the same everywhere because the evidence base is so strong. We know what to do. The problem is that we are failing to implement that knowledge.”
According to the new Lancet series, the chances of a woman dying from childbirth over her lifetime is about one in 4,900 in high-income countries, while for women in sub-Saharan Africa the figure is one in 36. By contrast, according to the World Health Organisation, the UK figure is one in 5,800.
“[What] drives some of the risk is that we still have high fertility in some parts of the world,” said Graham. “We still have large parts of low- income countries where there is a high unmet need for contraception.”
While births in the presence of skilled birth attendants rose from 57% to 74% between 1990 and 2013, the authors warn that many women in poor and rural settings do not have access to such care, while the increase in coverage does not necessarily mean such care is of high quality.
“There are still about 53 million women who have no care at all at the time of delivery,” said Graham.
“If you have coverage of care that is not good quality you are not going to prevent the deaths,” she added. “There is a non-trivial proportion of facilities that are called maternity units but don’t have running water, don’t have electricity, don’t have trained providers.”
Where women do make use of maternal healthcare services, the quality of care can vary dramatically, the authors add, with some receiving too little care, too late. That, they say, can be down to delays in recognising or accessing care, as well as poorly-equipped facilities, with too few staff and a lack of evidence-based care.
The situation, they add, can arise not only in low income countries, such as those in sub-Saharan Africa, but also in high- and middle-income countries due to social inequalities: black women were more likely to die in childbirth in New York in 2010 than women in North Korea or Vietnam.
The opposite end of the spectrum is also of concern, the authors write, citing the over-medicalisation of birth that they dub “too much too soon”, as shown by high rates of caesarean sections and induced labour as well as unnecessary ultrasound examinations and excessive use of antibiotics.
“You have countries like Brazil and parts of Latin America where about 40% of deliveries are by caesarean section, they are a very common procedure,” said Graham. “Now there is no way that 40% of women need a caesarean section.”
By contrast, around a quarter of babies in England and Wales are delivered by caesarean section, while almost 19% of births worldwide involve the procedure. “Globally, caesarean section rates are rising, and medically unnecessary caesarean sections are prevalent,” the authors report.
The authors also reveal that about 27 million cases of serious pregnancy-related complications occurred in 2015 from the five main direct obstetric causes including haemorrhage and problems arising from abortions. “Death is the tip of the iceberg,” said Graham. “Morbidity is a very large burden on families and health systems.”
The authors highlight a need for maternal healthcare services to respond to growing diversity in the health problems affecting pregnant women as well as the trend for women to have babies later in life. The latter, they say, includes offering care not just regarding the pregnancy and birth itself, but also taking into account that older mothers are more likely to have medical conditions that also need to be addressed and considered, as well as different preferences for their care.
“That joined-up thinking and that joined-up working among professionals and services doesn’t really exist in low income countries in many places on the scale that can respond to these epidemiological transitions,” said Graham.
Other challenges, the authors note, lie in the boom in people moving into urban centres, as well as the rise in obesity, pointing out that in 2014, 13% of mothers were obese.
“Again it is this issue of getting prepared for services to meet the needs of obese patients,” said Graham.
The report also highlights the need for emergency services to provide better maternal health care during crises, from outbreaks such as that of the Zika virusto mass migration, whether political or environmental.
“Your first line services have to recognise that pregnancy will continue and births will happen,” said Graham. “Systems need to be more resistant to what we call shocks – whether it is Zika or indeed ebola, shocks happen.”
“The new report makes it evident that there is a growing divide between the haves and the have-nots,” said Katja Iversen chief executive of Women Deliver.
“We have come far in bringing down maternal mortality, but we are definitely not there yet,” she added. “It is not just about increasing the number of health centres, it is also about women’s economic status in society. It is not just about increasing the quality of care that women receive, it is also about education, nutrition and equality. And it is not just about low income countries, it is also something that we see in pockets of very wealthy countries.”