Significant strides, but not enough
Most maternal deaths are preventable. In 2015, an estimated 303,000 women died of causes related to pregnancy or childbirth. A majority of them died from severe bleeding, sepsis, eclampsia, obstructed labour and the consequences of unsafe abortions – all causes for which there are highly effective interventions. And the tragedy does not stop there: When mothers die, their families are much more vulnerable, and their infants are more likely to die before reaching their second birthday.
But significant reductions in maternal mortality are possible, and they are taking place. The global maternal mortality ratio has fallen from 385 maternal deaths per 100,000 live births in 1990 to 216 deaths per 100,000 live births in 2015. In many countries – including Cuba, Egypt, Jamaica, Malaysia, Morocco, Sri Lanka, Thailand and Tunisia – maternal deaths have fallen as women have gained access to family planning and skilled birth attendance with backup emergency obstetric care. Many of these countries have halved their maternal deaths in the space of a decade.
But much more must be done. High rates of maternal mortality persist, particularly in impoverished communities. Of the hundreds of thousands of women who die during pregnancy or childbirth each year, over 85 per cent live in sub-Saharan Africa and Southern Asia.
Working for the survival of mothers is a human rights imperative, and it is a development priority. The International Conference on Population and Development and the Millennium Development Goals called for achieving a 75 per cent reduction in maternal mortality between 1990 and 2015; this remains an unfinished agenda. The new Sustainable Development Goals, also known as the Global Goals, call for bringing the maternal mortality ratio down to 70 deaths per 100,000 live births by 2030. The best way to achieve this ambitious target is to: ensure all women have access to contraception to avoid unintended pregnancies; provide all pregnant women with skilled and respectful care in a safe environment during delivery; and make sure women with complications have timely access to quality emergency obstetric care.
Complications of pregnancy or childbirth
For every woman who dies from causes related to pregnancy, an estimated 20 to 30 encounter serious complications. At least 15 per cent of all births are complicated by a potentially fatal condition. Women who survive such complications often require lengthy recovery times and may face lasting physical, psychological, social and economic consequences. Although many of these complications are unpredictable, almost all are treatable.
Without treatment, these conditions can kill, disable or lead to stillbirths. The costs of medical care and lost productivity can also drive women and their families into poverty. Obstetric fistula, for example, can result in chronic infections, social isolation and deepening poverty.
Prenatal care is an important part of basic maternal health care. It is recommended expectant mothers receive at least four antenatal visits, in which a health worker can check for signs of ill health – such as underweight, anaemia or infection – and monitor the health of the foetus. During these visits, women are counselled on nutrition and hygiene to improve their health prior to, and following, delivery. They can also develop a birth plan laying out how to reach care and what to do in case of an emergency.
Because these visits may be a woman’s first interaction with the health system, they are an important opportunity to assess her overall health, and to speak with her about her sexual and reproductive health and rights. In these settings, women learn the health benefits of spacing births and how to plan their families. They are also counselled on newborn care and the importance of birth registration.
Still, the great majority of complications arise with little or no warning among women who have no risk factors. While antenatal visits may not prevent complications, women who receive antenatal care are more likely to deliver with the help of a skilled birth attendant, who can recognize and address these issues.
Skilled birth attendance
Skilled attendance at birth, with emergency backup, is considered the most critical intervention for ensuring safe motherhood. Skilled birth attendants are health workers, such as doctors, nurses or midwives, who have the skills to manage normal deliveries and recognize the onset of complications. They perform essential interventions, start treatment, and supervise the referral of complications to emergency care. Skilled attendance is also vital for protecting the health of newborns, as the majority of perinatal deaths occur during delivery or in the 48 hours afterward.
Skilled attendance requires an enabling environment, such as a clean delivery area with the necessary supplies and equipment. And skilled birth attendants must provide respectful care that takes into account the dignity of the pregnant woman. Unfortunately, many countries have severe shortages of trained health providers with midwifery skills.
A pregnant woman awaits care in a clinic in Dili, Timor-Leste, where UNFPA has provided safe delivery equipment. ©UN Photo/Martine Perret
Emergency obstetric care
Emergency obstetric care is critical to reducing maternal mortality. All five of the major direct causes of maternal death – haemorrhage, sepsis, unsafe abortion, hypertensive disorders and obstructed labour – can be treated at a well-staffed, well-equipped health facility. In such settings, many newborns with asphyxia or infection can also be saved.
In case of complications, all women and newborns should have rapid access to well-functioning emergency obstetric facilities meeting good quality-of-care standards. And in the long term, all births should take place in appropriate facilities, as is the case in all countries that have managed to significantly reduce their maternal mortality.
Post-natal care – provided within the first 24 hours of delivery, on the third day afterward, then in the second and sixth weeks – is as important as antenatal care. Bleeding, sepsis and hypertensive disorders can all take place after a woman has exited the health centre. And newborns are also extremely vulnerable in the immediate aftermath of birth.
UNFPA strongly recommends follow-up visits by a health worker to assess the health of both mother and child in the post-natal period.
UNFPA at work
Making motherhood safer is a top priority for UNFPA. UNFPA works at all levels to promote universal access to sexual and reproductive health care and rights, including by promoting international maternal health standards and providing guidance and support to health systems.
UNFPA-supported programmes emphasize capacity development in maternal care, especially the strengthening of human resources and emergency obstetric and newborn care. Among its many programmes, UNFPA helps to train midwives, supports emergency obstetric and newborn care facilities and networks, and provides essential drugs and family planning services. UNFPA also supports the implementation of maternal death review and response systems, which help officials understand how many women are dying, why, and how to respond.
UNFPA additionally seeks to make pregnancy and childbirth as safe as possible in emergency settings. And UNFPA's work to prevent fistula is calling attention to health systems that are failing to meet the needs of women. UNFPA also supports fistula repair programmes, doubling the number of repairs supported between 2010 and 2013.