Maternal mortality is defined by the World Health Organization (WHO) as “the death of a woman while pregnant or within 42 days of termination of pregnancy irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. These maternal deaths are divided into two categories: direct obstetric deaths and indirect obstetric deaths. The latter are deaths for which there was a preexisting disease that was aggravated by the pregnancy. Maternal mortality remains a major problem in many parts of the world including Nigeria. Understanding the causes of maternal mortality is crucial in confronting the challenge of unyielding high rates.
In the year 2000 member countries of the United Nations agreed on 8 millennium development goals (MDGs) to improve the health and socio-economic well-being of the people in their countries in the 21st century. MDG 5 – to improve maternal health – set a target of reducing maternal mortality by three-fourth by 2015 (Target 5.A). Unfortunately, of all the MDGs, MDG 5 has made the least progress. The number of women dying due to complications during pregnancy and childbirth decreased by 34% from 1990 to 2008.The progress is notable, but the annual rate of decline is less than half of what is needed to achieve the MDG target. This will require an annual decline of 5.5%. The 34% decline since 1990 translates into an average annual decline of just 2.3%.
A woman dies every 90s from complications of pregnancy – over 500,000 every year. Majority (90%) of these deaths are preventable. A total of 99% of all maternal deaths occurs in developing countries, where 85% of the population lives. More than half of these deaths occur in sub-Saharan Africa. The maternal mortality ratio in developing countries is 450 maternal deaths/100,000 live births versus 9 in developed countries. A woman in sub-Saharan Africa has a 1 in 16 chance of dying in pregnancy or childbirth, compared to a 1 in 4000 risk in a developed country – the largest difference between poor and rich countries of any health indicator. Different interactive factors contribute to maternal mortality. The range is wide and includes the behavior of families and communities, social status, education, income, nutritional status, age, parity, and availability of health services. Non health sector activities, such as education, water and sanitation, roads and communication, agriculture, and internal security, also influence maternal outcome. In sub-Saharan Africa, some of the highest MMRs have been recorded in countries that are in conflict or have large refugee populations.
Women die from a wide range of complications in pregnancy, childbirth or the postpartum period. Most of these complications develop because of their pregnant status and some because pregnancy aggravated an existing disease. The five major killers are: Severe bleeding, infections, hypertensive disorders in pregnancy (eclampsia), obstructed labor and complications following unsafe abortion. Globally, about 80% of maternal deaths are due to these causes and every day, about 1000 women die due to them. Maternal deaths caused by improperly performed procedures are preventable and contribute 13% to the maternal mortality rate worldwide. This number is increased to 25% in countries where other causes of maternal mortality are low, such as in Eastern European and South American countries. This makes unsafe abortion practices the leading cause of maternal death worldwide
Several interventions prior to pregnancy have been recommended in efforts to reduce maternal mortality. Increasing access to reproductive healthcare services, such as family planning services and safe abortion practices, is recommended in order to prevent unintended pregnancies. Several countries, including India, Brazil, and Mexico, have seen some success in efforts to promote the use of reproductive healthcare services. Other interventions include high quality, which includes pregnancy prevention and Sexually Transmitted Diseases (STI) prevention and treatment. By addressing STIs, this not only reduces perinatal infections, but can also help reduce ectopic pregnancy caused by STIs. Adolescents are between two and five times more likely to suffer from maternal mortality than a female twenty years or older. Access to reproductive services and sex education could make a large impact, specifically on adolescents, who are generally uneducated in regards to carrying a healthy pregnancy. Education level is a strong predictor of maternal health as it gives women the knowledge to seek care when it is needed. Public health efforts can also intervene during pregnancy to improve maternal outcomes. Areas for intervention have been identified in access to care, public knowledge, awareness about signs and symptoms of pregnancy complications, and improving relationships between healthcare professionals and expecting mother.
Access to care during pregnancy is a significant issue in the face of maternal mortality. “Access” encompasses a wide range of potential difficulties including costs, location of healthcare services, availability of appointments, availability of trained health care workers, transportation services, and cultural or language barriers that could inhibit a woman from receiving proper care. For women carrying a pregnancy to term, access to necessary antenatal (prior to delivery) healthcare visits is crucial to ensuring healthy outcomes. These antenatal visits allow for early recognition and treatment of complications, treatment of infections and the opportunity to educate the expecting mother on how to manage her current pregnancy and the health advantages of spacing pregnancies apart.
Access to birth at a facility with a skilled healthcare provider present has been associated with safer deliveries and better outcomes. The two areas bearing the largest burden of maternal mortality, Sub-Saharan Africa and South Asia, also had the lowest percentage of births attended by a skilled provider, at just 45% and 41% respectively. Emergency obstetric care is also crucial in preventing maternal mortality by offering services like emergency cesarean sections, blood transfusions, antibiotics for infections and assisted vaginal delivery with forceps or vacuum. In addition to physical barriers that restrict access to healthcare, financial barriers also exist. Close to one out of seven women of child-bearing age have no health insurance. This lack of insurance impacts access to pregnancy prevention, treatment of complications, as well as perinatal care visits contributing to maternal mortality.
By increasing public knowledge and awareness through health education programs about pregnancy, including signs of complications that need addressed by a healthcare provider, this will increase the likelihood of an expecting mother to seek help when it is necessary. Higher levels of education have been associated with increased use of contraception and family planning services as well as antenatal care. Addressing complications at the earliest sign of a problem can improve outcomes for expecting mothers, which makes it extremely important for a pregnant woman to be knowledgeable enough to seek healthcare for potential complications. Improving the relationships between patients and the healthcare system as a whole will make it easier for a pregnant woman to feel comfortable seeking help. Good communication between patients and providers, as well as cultural competence of the providers, could also assist in increasing compliance with recommended treatments.
Another important preventive measure that is being put in is specialized education for mothers. Doctors and medical professionals providing simple information to women, especially women in lower socioeconomic areas will decrease the miscommunication that often occurs between doctors and patients. Training health care professionals will be another important aspect in decreasing the rate of maternal death
The WHO has also developed a global strategy and goal to end preventable death related to maternal mortality. A major goal of this strategy is to identify and address the causes of maternal and reproductive morbidity and mortality, as well as disabilities related to maternal health outcomes. The collaborations that this strategy introduces are to address the inequalities that are shown with access to reproductive, maternal, and newborn services, as well as the quality of that care. They also ensure that universal health coverage is essential for comprehensive health care services related to maternal and newborn health. The WHO strategy also implements strengthening health care systems to ensure quality data collection to better respond to the needs of women and girls, as well as ensuring responsibility and accountability to improve the equity and quality of care provided to women.