The latest Lancet series on maternal health reveals that nearly one quarter of babies worldwide are still delivered in the absence of a skilled birth attendant. Further, one-third of the total maternal deaths in 2015 happened in India, where 45,000 mothers died during pregnancy or childbirth while Nigeria shouldered the maximum burden of 58,000 maternal deaths. Each year, about 210 million women become pregnant and about 140 million newborn babies are delivered. Ahead of the U.N. General Assembly, The Lancet has published a new series of papers on maternal health which reveal that while progress has been made in reducing maternal mortality globally, differences remain at international and national levels. “In all countries, the burden of maternal mortality falls disproportionately on the most vulnerable groups of women. This reality presents a challenge to the rapid catch-up required to achieve the underlying aim of the Sustainable Development Goals [SDGs] — to leave no one behind,” says series author Professor Wendy Graham, London School of Hygiene & Tropical Medicine.
According to the academic papers, there are two broad scenarios that describe the landscape of poor maternal health care — the absence of timely access to quality care (defined as ‘too little, too late’) and the over-medicalisation of normal and postnatal care (defined as ‘too much, too soon’). “The problem of over-medicalisation has historically been associated with high-income countries, but it is rapidly becoming more common in low and middle-income countries, increasing health costs and the risk of harm. For instance, 40.5% of all births are now by caesarean section in Latin America and the Caribbean,” stated one paper. While facility and skilled birth attendant deliveries are increasing in many low-income countries, the authors say that phrases such as ‘skilled birth attendant’ and ‘emergency obstetric care’ can mask poor quality care. Additionally, many birth facilities lack basic resources such as water, sanitation and electricity. The authors warn that measuring progress via the current indicator of skilled birth attendant coverage is insufficient and fails to reflect the complexity of circumstances. “It is unethical to encourage women to give birth in places with low facility capability, no referral mechanism, with unskilled providers, or where content of care is not evidence-based. This failing should be remedied as a matter of priority,” added Professor Oona Campbell, London School of Hygiene & Tropical Medicine.
In high-income countries, rates of maternal mortality are decreasing but there is still wide variation at national and international level. For instance, in the U.S., the maternal mortality ratio is 14 per 1,00,000 live births compared to 4 per 1,00,000 in Sweden. The sub-Saharan African region accounted for an estimated 66% (2,01,000) of global maternal deaths, followed by southern Asia at 22% (66,000 deaths). However, the authors warn that not all care is evidence-based, and improved surveillance is needed to understand the causes of maternal deaths when they do occur. Additionally, they point to new challenges in delivering high quality care, including the increasing age of pregnancy , and higher rates of obesity.