Most women who give birth in the United States do so surrounded by a variety of health professionals, including doctors or midwives, nurses and doulas. The combined expertise in the room ensures that if something goes wrong, the best care possible is at hand.
Such is not the case in many developing nations. A recent report from Nigeria estimates that 20 percent of births there take place in “NOP” conditions, meaning No One Present. The birthing mother delivers her own baby, cuts its cord, and tends to herself. Hard to imagine.
Worldwide, more than half of all births in developing nations take place without a doctor, midwife, nurse, or skilled attendant present. Too often, the outcome is tragic: an estimated 287,000 women still die in childbirth every year, in what are mostly preventable deaths. Another 5.7 million women suffer, sometimes permanently, from heinous disabilities related to childbirth, such as fistula, which is largely preventable with proper care.
Can steady and expanded efforts by the global health community make maternal mortality and disability go the way of polio and small pox?
Astounding improvements over the last 20 years suggest that the world is moving this direction. The latest estimates suggest that, since 1990, maternal mortality has declined by half, often in some of the world’s poorest places. This September, the Republic of Congo became the latest developing nation to announce it has cut maternal mortality rates in half, with 426 women dying for every 100,000 birth, down from 726 in 2006—too many, but an improvement indeed.
In 2000, the UN made the reduction of maternal deaths worldwide the fifth of its eight UN Millennium Goals, and it is still the goal that lags the furthest behind. It seems almost bizarre that the global health and development communities have not made more progress on this issue—given that, from a clinical perspective, the causes of maternal death and disability are well understood and the solutions are tried and true. In fact, experts estimate that 99percent of all cases of maternal mortality could be prevented with existing and often fairly low-tech interventions.
Post-partum hemorrhage is the leading cause of maternal death worldwide but it could be combated with drugs developed over the last decade, such as Misoprostol and Oxytocin. Oxytocin must be refrigerated and injected, which is a barrier in countries with weak health care infrastructures. Misoprostol comes in a pill form that could be delivered at the community level by community health workers; however, it doubles as an abortion drug, and that stigma alone prevents widespread distribution.
Infection, another major killer, could be prevented with clean birthing practices. The safe childbirth checklist, a project spearheaded by Atul Gawande, is a simple but enormously effective innovation for encouraging health workers to pay attention to the steps involved in a safe and clean birth. Early studies in India have shown remarkable results, with a big uptake in handwashing, which happens to be one of the most critical interventions for preventing infection. Still, a simple checklist can’t possibly solve all of the barriers to improving maternal health around the world. An intervention like this requires a well-trained and motivated health workforce. It also requires health facilities to be stocked with the supplies needed for health workers to carry out the tasks on the checklist.
While the technology and the clinical interventions exist, experiences in actually implementing and scaling up maternal health programs in a range of geographic settings have shown that achieving lasting improvements for the health of mothers requires more than medical interventions. It requires access to education for girls, improvements in gender equity, more access to family planning and skilled birth attendants, and sustained investments in health systems. It is also important to note that, unlike vaccine preventable diseases where risk can often be eliminated with a single shot, when it comes to maternal death and injuries related to childbirth, women continue to be at risk with each pregnancy. This means that women must rely on sustained improvements in access to and quality of care over the long haul.
The biggest reductions in maternal death over the last 20 years have largely occurred in places where local governments have installed policies to address these issues. Bangladesh, Ecuador, India, and Rwanda have each seen a greater than 50 percent reduction in maternal mortality. They have done so by initiating a number of programs and policies that focus on lasting impact over quick fixes. Approaches in these countries have included providing more and higher quality training to health workers in urban and rural settings and increasing access to affordable health care for all, including the most marginalized. Several countries that have seen big progress have also experimented with task-shifting. For example, in Bangladesh, midwives have been trained to provide emergency obstetric care, including Cesarean sections, a task usually reserved for physicians. Bangladesh has also placed new emphasis on education for girls, an important step that has likely contributed to reductions in maternal mortality as well as improvements in a number of other social and health indicators.
Home births are so common in places like India, that the government launched a program to provide financial incentives for women to give birth in clinical settings, an approach that seems to be getting women to the facilities in large numbers. However, big challenges remain in terms of equipping those facilities with the supplies and human resources to save lives. In India, many facilities were not prepared for the influx of women resulting from the announcement of cash incentives. Overcrowding and insufficient staffing have led to poor quality of care; in some cases, pregnant women had to be turned away after long, difficult, and costly journeys.
Mahmoud Fathalla, chairman to the advisory committee on Health Research for the World Health Organization Eastern Mediterranean Region, and lifelong advocate for maternal health, often points out, “Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.”
Yes, maternal mortality and morbidity are down, especially in places where policymakers have made the decision to invest in women’s lives, but they are not down enough. The global health community has the technical solutions, so the challenge is implementation—how do we put all of these proven and effective interventions together into comprehensive programs that meet women’s health needs? How do we reach the most vulnerable and marginalized populations in the world in a way that is acceptable to those populations? Resolving that challenge will be the final stage in making birth everywhere in the world what it should be: the happiest moment in a woman’s life, not the last.