Welcoming a child into the world should always be a joyous occasion. Yet the tragedy remains: many women in low and middle income countries still continue to die during pregnancy, delivery or after childbirth. Every year, about 287,000 women die worldwide due to pregnancy or birth-related complications. Half of these deaths occur in sub-Saharan Africa, where women face a 1 in 39 lifetime risk of dying during pregnancy. The reality, uncomfortable as it is to accept, is that most of these deaths are largely preventable.
The story begins a quarter of a century ago, in Nairobi (1987), where the global Safe Motherhood Initiative was launched, seeking to identify effective interventions and mobilise resources to prevent maternal deaths. As the years churned on into the new millennium, with little progress observed, there was an unprecedented opportunity to refocus on maternal health through the Millennium Development Goals (MDGs). The fifth MDG has the target of reducing 75% of maternal deaths by 2015.
In 2008, for the first time, signs of a slight decline in global levels of maternal mortality were jointly reported by the World Health Organization, UNICEF, UNFPA and World Bank, and subsequently this was confirmed by the updated 2012 maternal mortality trend estimates. This was good news indeed, with success stories reported mainly in Asian countries such as Bangladesh, Cambodia, Nepal and China. Strikingly, only two sub-Saharan countries i.e. Equatorial Guinea and Eritrea, shared the same success stories as Asian countries, of reaching the 75% reduction target set. Many more low and middle income countries are currently far from their target, and the fifth MDG still continues to remain as “the most off track goal” in these countries.
The complexities of how to reduce maternal deaths requires broad and ambitious interventions. The challenges resulting from the inability to make precise measurements of the burden of mortality underlie other factors. These factors include broad social issues such as inequalities, the poor social status of women, as well as other barriers of lack of education, difficulty in accessing healthcare, lack of adequate healthcare systems, delayed referrals, early marriages, lack of contraception and poor nutrition. These factors increase the vulnerability of a woman and lead on to her susceptibility to die of life-threatening complications during pregnancy and childbirth.
Knowing what works in terms of reducing maternal mortality is important, but it is often complicated by the diversity of different country contexts. Some important strategies have been suggested by Oona Campbell and Wendy Graham (2006) targeting the antepartum, intrapartum and postpartum levels of care. These have also been mentioned in a WHO Factsheet and other sources. Although there is overwhelming evidence on what to do to prevent maternal deaths, no magic bullet exists.