DIGEST March 2024

Thinking about maternal deaths as a social issue, not just a medical problem

Earlier this year, as I reviewed the latest evidence on global maternal mortality, I was shocked to realize that, after making progress consistently since the 1990s, many countries seem to be stalling or even regressing in stopping totally preventable deaths during pregnancy and childbirth. Globally, there has been no progress at all since 2016.

As a result, in 2020, an estimated 287,000 pregnant women still died tragically and unnecessarily. That’s almost 3 million lives lost between 2010 and 2020. And these recent global numbers stop at 2020, so the next set of figures could be even worse given COVID, which affected pregnant persons disproportionately. It’s very concerning, to say the least!

A series of recent in-depth articles published in December 2023 in medical journal The Lancet seeks to analyze the problem and identify solutions. Here is the current state of affairs, including a breakdown by region:

“At the halfway mark to 2030, the [Sustainable Development Goal or SDG] of reaching a global maternal mortality ratio (MMR) of 70 maternal deaths per 100,000 livebirths remains elusive, with 223 maternal deaths per 100,000 livebirths reported in 2020. This figure is much less than the MMR for 2000, which was 339 maternal deaths per 100,000 livebirths. However, since 2016, the MMR has decreased in only two regions: central and south Asia, and Australia and New Zealand. Sub-Saharan Africa, Oceania (excluding Australia and New Zealand), east and southeast Asia, and north Africa all experienced a stagnation in the MMR. During this time period, the MMR increased in Europe, North America, Latin America, and the Caribbean.”

I reached out to two of the authors of the Lancet series to hear more. Both are renowned experts in maternal health, based in the Department of Sexual and Reproductive Health at the World Health Organization in Geneva. Dr. Femi Oladapo, MD, is Head of the Maternal and Perinatal Health Unit, while Dr. Jenny Cresswell, an epidemiologist, is the Technical Lead for Measurements and Monitoring.

Dr. Oladapo described the most recent data as “an eye opener,” but also as an opportunity to rethink what can and should be done. Both experts noted that the issue is really not about biomedical knowledge anymore. As noted in the January 2024 Famous Feminist Newsletter, we have known what to do on a medical level to avert maternal deaths for several decades now. Medical interventions and procedures to address excessive bleeding, infections, obstructed labor or dangerous high blood pressure during and after pregnancy and delivery or to ensure safe abortions are well known and not particularly complex or costly, but these interventions are still not reaching all those who need them. Of course, as Dr. Oladapo noted, there should always be more innovation and research in maternal health: “Compared to HIV or even TB and malaria, there is not much investment in developing new drugs to prevent maternal deaths”—to address postpartum hemorrhage, for example.

Overall, the main problem is now elsewhere, as the Lancet series makes clear: “Focusing solely on biomedical causes of maternal mortality is insufficient and has possibly been the cause of many countries remaining at the same maternal mortality transition stage for decades. Maternal mortality is a social issue, not just a medical problem,” the Lancet series argues. “It is deeply shaped by the broader context in which pregnancy occurs.” What if, instead of thinking about maternal mortality solely as a medical question to be resolved by specific interventions, we examined that broader context?

The Lancet articles zoom out from the bedside to identify some of the most consequential solutions. When it comes to the health care system itself, it is clear that poor quality of health care remains a fundamental driver of maternal deaths. Recalling his years of practice as an obstetrician-gynecologist in his home country of Nigeria, Dr. Oladapo described health facility deficiencies that remain all too common in many countries of sub-Saharan Africa: “I lost a patient once from severe blood loss. We had no blood in the blood bank. I had to drive in the middle of the night to a private blood bank to get the blood because the hospital ambulance wasn’t working. It was raining heavily, and the road was flooded. It took me half an hour to get there. By the time I came back, she was already dead.” He is still shaken, years later.

In addition to that kind of basic health system failure, Dr. Oladapo noted that, in too many places, out-of-pocket health care costs remains prohibitive for many people: “Everyone says, oh, African women don’t come early enough to the hospital. Women get to the hospital too late because they don’t have the money to pay.” One of the Lancet series’ major findings was the need to make reproductive health care free of charge at the point of service. Similarly, WHO’s Roadmap to combat postpartum haemorrhage, published in October 2023, shows that the abolition of “user fees” saves lives: “In African countries where the burden of postpartum hemorrhage is high, as soon as you take user fees out, you see a sharp decline,” noted Dr. Oladapo.

“My one-sentence summary is universal health coverage,” said Dr. Cresswell, that is, “a full range of health services, but also affordability and accessibility. It’s about women getting timely, good quality access to a full spectrum of sexual and reproductive health services when they need it.” In addition to maternal mortality being a tragedy, Dr. Cresswell described it as a “canary in the coal mine” or as a “tracer indicator” for health systems. “It is one of the things we track closely in sexual and reproductive health care,” she added. “If the level of maternal mortality is high, it’s strongly suggestive that the broader package of sexual and reproductive health care is being neglected.”

Access to a full range of sexual and reproductive services is critical. The Lancet series emphasized that what needs to be offered isn’t just care at the moment of childbirth: “Expanding demand for and access to high-quality reproductive health services and commodities (including safe abortion, modern contraception, and antenatal, intrapartum, and postpartum care) are needed for primary prevention, early identification, and adequate management of pregnancy, labor, and postpartum complications.”

The Lancet series also finds that those most at risk of dying during pregnancy and childbirth are primarily those pregnant persons who are already otherwise disadvantaged, whether in terms of race, ethnic origin, social class or migrant status, among other factors. “The inequity issue is huge in maternal mortality,” said Dr. Cresswell. Even within countries where maternal mortality is relatively lower, “it is the women who are struggling to access care who are more likely to die, be they migrant or refugee women, women who don’t speak the vernacular language, women who are discriminated against ethnically or racially, those discriminated against on account of age,” she added. One of the papers in the Lancet series examined access to antenatal care in eight Latin American and Caribbean countries and found that poorer Black or Indigenous women had lower access to quality antenatal care: “Socioeconomic deprivation combined with ethnic disadvantage served to push these women below national averages.” Sounds obvious, right?

As I noted in the January 2024 Newsletter, the rise in the U.S.’s MMR is driven by a stark increase in the deaths of Black women. Meanwhile, in Europe, migrants are seeing their access to health care increasingly curtailed, especially (but not only) if they are undocumented. A 2018 WHO report on the health of refugees and migrants in Europe noted that, compared with non-migrants, “migrant women face poorer pregnancy and birth outcomes with a higher incidence of caesarean sections and complications, suggesting a lower access to family planning and prenatal checks.” As Dr. Oladapo pointedly told me, “if minority groups are the ones affected, then being that minority is the issue.”

Gender inequality combines with these issues in multiple, intersectional ways: “When girls are not going to school to get empowered, to understand how and why to seek proper health care, you can provide as much oxytocin [to stop bleeding] as you want, they’re never going to receive it,” Dr. Oladapo noted. “When women are disempowered, cannot work, don’t have economic resources, when there is no gender equality, when all of these cultural, political, ideological conditions interfere, just getting the medication to the bedside isn’t going to do it. Because the women are not even going to come if they need their husband’s permission to visit the hospital when they are sick. If you get girls into school, if you deal with gender inequality, the impact is certain.” One crucial approach to advancing gender equality is, of course, supporting the work of feminist groups who are painstakingly and consistently working to change gender norms and ensure that women and girls thrive.

One of the series’ papers provides a useful set of prompts on how to embed intersectional equity into everyday practice. For example, “are health workers trained and experienced to work with specific populations, e.g., people who are transgender or non-binary, migrants, or refugees? Are services available and accessible to all people who need them, e.g., regardless of marital status, age, language, disability, gender identity? Are there policies that allow for a labor companion of the woman or the birthing person’s choice, and practical actions to ensure that all who want a labor companion are able to have one? Do women or birthing persons need permission from a male partner or family member to visit a health facility? Are maternity care services covered by insurance, free of charge, or covered by non-governmental organizations?”

While maternal care used to be somewhat exempt from ideological attacks from conservative actors, that is no longer the case. In an op-ed in the Lancet series, Dr. Oladapo recounts attending a session of the UN Human Rights Council in the fall of 2023, when a resolution on preventable maternal mortality and morbidity and human rights was being debated. “Rights-based approaches to ending maternal mortality were questioned, including those relating to access to contraception, safe abortion care, prevention of gender-based violence and harmful practices, and comprehensive sexuality education.”

When I asked him to elaborate on that experience, Dr. Oladapo said, “I couldn’t believe what I was hearing. I was surprised that maternal health that used to be everybody’s love child, their bread-and-butter topic—you know, no one wants women to die—was getting entangled. Now some diplomats were saying: ‘Oh! contraception has nothing to do with maternal mortality, because the woman doesn’t get pregnant.’” He shook his head in disbelief: “There’s no maternal mortality reduction without addressing the gaps in sexual and reproductive health services. It makes zero sense! We don’t want women to die, but we don’t want to help them prevent the pregnancies they don’t want, leave a violent relationship or learn about sexuality? It’s nonsensical.”

Nonsensical indeed. As we have seen in the U.S., banning safe abortion care directly endangers women’s lives. Among other impacts, it cuts access to overall obstetric care by preventing health providers from performing a critical medical intervention that many patients need during pregnancy, and by causing these providers to move away to places where they can practice medicine or nursing without fear of being arrested. More “health diplomacy,” as Dr. Oladapo calls it, or what feminist groups call advocacy and campaigning, will be needed to combat the far-right onslaught against sexual and reproductive health and rights. And, of course, electing political leaders that prioritize sexual and reproductive rights and justice.

While the worsening situation in the United States and in some countries of Europe has generated some media coverage, “we shouldn’t forget the worst ratios are still in sub-Saharan Africa,” noted Dr. Cresswell. “In these highest maternal mortality countries, your lifetime risk of dying is 1 in 30 or even 1 in 20. These are the settings where—and this is not a surprise—we have persistent instability, civil war, ongoing humanitarian crises. These situations create prolonged disruptions to health systems. I’m talking countries like South Sudan, Chad, like large parts of Nigeria, where the burden of maternal mortality is huge. And it hasn’t really changed at all for 20 years.”

But there are a number of countries that have gone against the tide and continued to reduce their maternal mortality ratio since 2016, noted Dr. Cresswell: “There has been quite remarkable work in several countries. In all cases, it’s about getting women good, timely access to care. In the Southeast Asian region, for example, Sri Lanka is a fantastic example.” Sri Lanka has focused on using data to learn from each maternal death: “A lot of countries review their maternal deaths, but Sri Lanka has been very diligent in making sure that there is a true feedback mechanism, so that changes can be made to improve care.” Other countries that have continued to improve since 2016 include the Maldives, Bhutan, Cape Verde, Ethiopia and Zambia.

A 2020 World Bank analysis of what measures “exemplars” such as the Maldives and Zambia have taken to continue to reduce maternal deaths shows similar approaches with respect to the health system: strong political leadership, dedicated investments in maternal health programs including detailed plans at the local and district level, and a significant increase in the number of nurses and midwives. Make maternal health a political priority in your overall planning and budgeting, and the results will follow.

As for the impact of COVID, which will be reflected in the next set of data, Dr. Cresswell noted that it seemed to operate on multiple levels: “Maternal deaths occurred because of the physiological impact of pregnancy and women’s immune response to COVID. There is also some evidence that COVID was a risk factor for severe hypertension, which could lead to pre-eclampsia. But there were also maternal deaths where the woman herself didn’t have COVID at all. Instead, it was due to pandemic-related factors on access, utilization or the quality of care. Because of lockdowns, she wasn’t allowed to go out and seek care when she felt unwell. Some wards were closed. Or she made it to hospital, but her partner couldn’t come with her because of restrictions on visitors, and then she had no one to advocate for her.” The key is making sure that reproductive health care remains a priority even during epidemics or other emergencies.

A social problem with clear solutions. We just have to make sure our leaders commit to implementing them. Or, as U.S. President Franklin D. Roosevelt famously told railway workers who were asking for his help, "I agree with what you've said. Now go out and make me do it."

In solidarity with all those making it their mission to save the lives of pregnant persons,