A woman’s risk of death during pregnancy, over a lifetime, in Sub-Saharan Africa is 47 times higher than it is for me, a woman from the United States.1 Millennium Development Goal 5"”reduce maternal mortality by 75% from 1990 to 2015"”is stalled. It is a goal that the development community pays lip service to, but maternal mortality in many countries has plateaued or, in places of instability, increased. Compounding the failure to make headway on this goal are the inherent and grotesque geographic and socioeconomic inequities of maternal mortality.
We know what to do"¦.right?
We know that most maternal deaths are preventable, have direct and indirect causes, and we have identified key interventions that work"”uterotonics for hemorrhage, magnesium sulfate for hypertension, and proper nutrition and iron folate tablets for anemia to name a few. We know that countries with the highest maternal mortality are fragile states, reinforcing the relationship between maternal mortality and women’s empowerment, health systems and social factors. However, we have yet to demonstrate how to systemically counter each of these risk factors from both the supply- and the demand-side. Many of the key interventions only address two or three causes of maternal mortality, but it is going to take a lot more than synchronous single interventions or integrated care models to solve a problem this complex. Although there is a broader global movement behind improving the health of mothers and children, we failing to put forth a concerted effort to address the multitude of clinical and cultural factors that impact maternal mortality.
What will it take?
Reducing maternal mortality requires three coordinated socio-systemic activities. Firstly, improving the functioning of health systems as a whole, which includes structural and process of care improvements. Examples of structural improvements are clinical infrastructure and human resources, whereas process of care includes the scope of service packages and quality of care. In one of the largest studies ever conducted on maternal complications and "˜near misses’, assessing over 300,000 women in 29 countries, it was found that universal coverage of "˜essential’ care packages is not enough. Essential maternal care needs to be coupled with emergency obstetric care and quality improvements.2
Many of the existing interventions for maternal health decrease adverse consequences of biomedical complications, but are not enough to alleviate the social contributions to poor maternal health and equity. Thus we must also focus on the social determinants of maternal health, including poverty, cultural and gender norms, age, ethnicity, religion, economic status and/or geographical location, which can impede access to quality maternal care. Maternal mortality prevention must address social barriers to care-seeking behavior and perceptions about the importance of maternal health, such as the beliefs of mothers-in-law and proper self-care practices.
Finally, the prioritization of maternal health needs to shift, not only by the mothers themselves, but also by the international development community in general. We tend to group maternal health with newborn and child health. In fact, the grouping has further proliferated, evolving from maternal and child health (MCH) to maternal, newborn and child health (MNCH) to RMNCHA, now including reproductive and adolescent health. The support for the grouping of RMNCH +A has recently shown unprecedented growth through key partnerships including Every Women, Every Child, the G8 Muskoka Initaitive, Committing to Child Survival: A Promise Renewed, and FP2020. Healthcare at each of these stages of life is equally important and interrelated, but each requires different interventions. The social and health interventions that save children are not the same as the ones that save their mothers. Saving the mothers is more complex, relying on a holistic health services response rather than vertical interventions such as disease-specific programs and immunization. This grouping has been detrimental to the focus and funding of maternal mortality.
The Bigger Picture
For global health practitioners, the familiarity with the reality of maternal mortality globally makes the stagnation in our efforts even more striking. In tribute to International Women’s Day, I want to put maternal mortality at the top of our agendas. Strategic investment in preventing maternal deaths must be a priority and we need to scale up our efforts three to four times, by dedicating adequate time and attention to improving the functioning of health systems, addressing social determinants of health, including demand-side awareness, autonomy and trust, and disentangling the funding on maternal health from child and newborn health (MDG 4). None of these points are new or groundbreaking, but focusing on maternal mortality, a cause that people can passionately rally behind, is a more effective platform for health system changes, than support for systemic improvements as a stand alone.
International Women’s Day is about supporting women. Let us take action to support the women who face the unacceptably high risk of death and disability from giving birth. No woman should have to fear giving life.
A special thanks to Erik Josephson & Kimberly Hirsh for insights and comments
1. United States Agency for International Development (USAID). Ending Preventable Maternal Mortality: USAID Maternal Health Vision for Action. June 2014. http://www.usaid.gov/sites/default/files/documents/1864/MCHVision.pdf
2. Souza, JoÃ£o Paulo, Ahmet Metin GÃ¼lmezoglu, Joshua Vogel, Guillermo Carroli, Pisake Lumbiganon, Zahida Qureshi, Maria JosÃ© Costa et al. “Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study.” The Lancet 381, no. 9879 (2013): 1747-1755.