Every minute of every day, somewhere in the world a woman dies as a result of complications arising during pregnancy and childbirth. Clare Shaw looks at what can be done to prevent so many unnecessary deaths.

Around 600,000 women die every year as a result of complications arising from pregnancy and childbirth, according to the World Health Organisation. And 99% of these deaths happen in developing countries.

Many of these women are young and otherwise healthy, with a role in the lives of their family, community and society. Yet they die prematurely – not as a result of disease or conflict, but from the natural process of giving birth to new life.

The beginning of one life should not mean the end of another, so what goes wrong? A quarter of all maternal deaths are caused by severe bleeding. Blood loss can kill rapidly if appropriate medical attention is not quickly available. Another avoidable killer is infection, often as a consequence of poor hygiene. This causes around 15% of deaths – which could be avoided by improved hygiene during delivery, and the use of appropriate antibiotics where any infection has occurred. A further one in ten deaths is caused by high blood pressure and related hypertensive disorders, mainly eclampsia. Again, many of these could be prevented by a combination of monitoring during pregnancy and simple drug treatment.

Prolonged or obstructed labour also kills thousands of women in developing countries, especially as this problem is more common in areas of malnutrition. It is also more likely in girls who become pregnant before they are fully grown themselves, which is often a result of early marriage and lack of access to adequate information about reproductive health. Family planning information and services could also help prevent the substantial proportion of maternal deaths (approximately 13%) which occur due to complications of unsafe abortion.

But even these horrific statistics do not tell the full story. For every woman who dies in childbirth or pregnancy, millions of others are left damaged or disabled, often with devastating problems that can last a lifetime. These problems commonly include incontinence, anaemia, infections or constant pain. Many women also find sex has become painful because of damage done during delivery, and some are left infertile.

Poor maternal health is not just an issue that should concern women – it affects the whole of society. Although their contribution is often unrecognised and unrewarded, women play an essential part in society in developing countries. They hold their families together, providing food and water, and care for the young and old. They are often the only breadwinner. The death of a mother, therefore, will have a huge effect on the rest of the family. If the new baby survives the birth, without its mother the chances of an early death are greatly increased. In fact, all remaining children in the family are more likely to die without the care of their mother. Where the woman is left ill or disabled after birth, the consequences are also devastating. No longer able to take on her previous responsibilities, her family will become poorer, increasing the burden on the community at large and undermining its development.

Rates of maternal mortality are an indicator of women’s social and economic standing – their limited access to health and education services and the economic opportunities available to them. In developed countries, the maternal mortality ratio is on average around 27 maternal deaths per 100,000 live births. In developing countries, the ratio is nearly 20 times higher, at 480 per 100,000. Some areas have mortality rates as high as 1,000 per 100,000.

Maternal mortality is a key issue for the entire development community, and one of the internationally agreed development targets is a 75% reduction in maternal mortality by 2015. According to International Development Secretary Clare Short, “Nowhere are the obstacles faced by women to health – and the inequalities faced by poor women – revealed more starkly than in the figures for maternal mortality. The tragedy and indecency is that we know the major causes of maternal mortality, and the kind of care that pregnant women need when things go wrong. Without better access to improved basic obstetric care for those who need it, women will continue to die in pregnancy and childbirth. We must do better. These are not principally matters of science. They are matters of political and moral choice and will.”

From the 1930s, maternal deaths fell dramatically in developed countries, thanks to advances in obstetric care and the increased prevalence of skilled birth attendants. In developing countries, however, many women are assisted in delivery by traditional birth attendants or by relatives, while others may have to deliver alone. Only 53% have the assistance of skilled health professionals – a midwife or doctor – while less than half give birth in a hospital or health centre. Yet as many as four in ten women will have complications that require some form of special care while giving birth.

Many developing countries have an acute shortage of skilled birth attendants, especially in rural areas. In some cases, traditional birth attendants have been trained in the promotion of safer birth practices, and taught to identify problems. This at least increases women’s chances of receiving life-saving medical care – including transfer to medical centres, where they can receive appropriate drugs or surgery.

“Safe motherhood is perceived as a human right, underpinned by laws that support effective action to increase women’s access to appropriate services… The health sector is encouraged to make good-quality services, including essential care for obstetric complications, available to all women during pregnancy and childbirth, with particular emphasis on ensuring that a skilled attendant is present at every birth,” says a joint statement on maternal mortality issued by WHO, UNFPA, UNICEF and the World Bank. Until these services can be made widely available in developing countries, this unnecessary tragedy will continue to affect millions of women, their families and their communities.

Improving obstetric care.

“Providing skilled attendants able to prevent, detect and manage the major obstetric complications, together with the equipment, drugs and other supplies essential for their effective management, is the single most important factor in preventing maternal deaths.” Joint statement issued by WHO, UNFPA, UNICEF and the World Bank.

The Dugald Baird Centre, based at the University of Aberdeen in Scotland, is one of the organisations collaborating with partners in developing countries to improve the quality of essential obstetric care available to women.

Based in four district hospitals in Ghana and Jamaica, this research study used audit methods adapted from the National Health Service across the UK, known as ‘criterion-based audit’. Taking the five major causes of maternal mortality, 37 ‘best practice’ criteria were worked out which required a simple ‘yes/no’ answer, according to the separate needs of the two countries. These looked at the type of clinical care required by women giving birth, and the lessons that could be learned from the UK experience, and produced a statistically significant improvement in obstetric care.

“This is an objective and educational approach to improving obstetric care,” says Professor Wendy Graham who led the work in Aberdeen. “In the longer term, I hope other countries will be able to adopt the same model and adapt it for their own needs.”

The objective nature of the study encouraged the participants to be honest, an approach that was welcomed in the participating hospitals. According to Kojo Yeboah-Antwi, the project worked well in the Ghanaian hospitals: “Unlike other audit processes, it was not seen as judgemental and this motivated the staff in its implementation… It gave them confidence that they could improve on quality of care without massive infusion of resources.”

Dr Deanna Ashley from Jamaica’s Ministry of Health agrees. “This approach ensured that the team took responsibility for the results and together prepared the plans to improve the quality of care being provided,” she said. “Overall, the study was a success, and the international collaboration was an enriching experience."

Where are women dying?

www.who.int

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