New Study Says Maternal Health Needs a "Radical Reappraisal"
By Amie Newman — September 26, 2016
According to a first of its kind global maternal health series published by The Lancet this month, more women survive childbirth now than they did 25 years ago. Maternal deaths have fallen by almost half since 1990.
That’s the good news. The bad news is that not all women and not all countries are part of this progress.
The Lancet series studied where and how we fell far short of the Millennium Development Goals (a set of time-bound global development commitments agreed upon by almost 200 country governments), where and how progress has been made, and calls for a “radical re-appraisal” of maternal health care to meet a new target goal (one of the Sustainable Development Goals). The clearest bell sounded in the series is the message that all women and newborns have a right to good quality care.
The good thing about this guiding message is that it’s universal and bridges even the most devastating of disparities in maternal death rates. No matter where one lives, quality care can save lives.
Ninety-nine percent of maternal deaths occur in developing countries. For example, in sub-Saharan Africa, a woman’s lifetime risk of dying during pregnancy or childbirth is 1 in 36, compared to 1 in 4,900 in high income countries.
There are many reasons why women die during childbirth: severe bleeding (often postpartum), infections after childbirth, high blood pressure during pregnancy (pre-eclampsia and eclampsia), complications from birth, unsafe abortion, and complications caused by or related to malaria, and AIDS during pregnancy. Most of these deaths could be prevented with access to quality care.
Yet not all disparities fall easily along developing versus developed country lines. The United States, in fact, while having far fewer maternal deaths, has actually seen the maternal mortality rate increase in a 25 year period. Researchers are “puzzled” about why. Some believe that the growing number of chronic conditions, including heart disease and diabetes, are to blame. One thing we do know is that not all women in this country face equal risk. As I wrote in a previous blog post about the racial disparity in maternal mortality statistics:
The existence of disease may be a medical cause of death but racial inequities are in part responsible for the increased numbers of black women dying. We live in a country where a host of injustices contribute to this devastating gap in well-being, including lack of access to health care, affordability, and quality of health care.
In lower income countries, inequities in income and educational levels can also prevent women from accessing quality care. The Lancet series, then, doesn’t try to offer a one-size fits all solution. What it does do is provide direction for ways in which quality care must be balanced so as not to fall into one of two extreme situations, “too little, too late” (TLTL) or “too much, too soon (TMTS)”, writes one set of researchers.
In the case of wealthier countries, including the United States, TMTS refers to the over-medicalization of normal pregnancy and birth, and interventions that are not rooted in evidence which can then cause harm as well as increase medical costs. Think: induction of labor, episiotomies, and medically unnecessary c-sections.
To be clear, these situations are not the cause of most maternal deaths in the world. But the overuse of interventions when they are not medically necessary contributes to complications, the medicalization of birth, and women not receiving the care and support they want and need while giving birth. These situations can and do exist for women in lower and middle income countries, as well, though it’s not nearly as common.
On the other end of the spectrum there’s the TLTL situation: “too little, too late.” Even in developing countries and middle-income countries where maternal mortality has decreased over the last couple of decades, death rates remain distressingly high. These are the areas of the world where women are most vulnerable to dying from pregnancy or childbirth complications. Too little, too late care includes situations where women don’t receive timely care, they birth in a facility without adequate equipment or medicine, they birth alone (or not in a facility at all), or in a facility without emergency care. There is a shortage of skilled providers for women in these vulnerable regions of the world and a lack of sufficient training, as well. And, as I wrote above, there are certainly women who live in wealthier nations who have less or little access to quality healthcare because of a host of inequities.
Maternal health is a human right. Improving the health and well-being of women during pregnancy, childbirth and in the weeks after childbirth requires global action to ensure this right. The Lancet series offers a five-point action plan to help achieve this vision. But it’s up to all of us to continue to work toward a cultural and political shift that provides pregnant, laboring, and postpartum women with the information, knowledge, and access to care they deserve.
Plus: For an excellent multi-faceted look at birth in the United States, including her own personal experience with having a C-section and a powerful story of one woman’s experience with freezing her eggs and surrogacy, check out Lisa Ling’s digital series, “This is Birth.”
I find it particularly interesting that you choose to mention both the “Too little, too late” problem as well as the “Too much, too soon” problem that is quickly becoming an issue in developed/high income countries. Most issues we hear about regarding maternal deaths revolve around lack of care, or care received too late. This is the first time I’ve seen mentioned complications (even though they may not always result in death) from too much, too soon. I believe more light needs to be shed on this idea, as child birth in developed countries is becoming more of a scheduled convenience rather than a natural life event. Working in the healthcare industry, I am seeing more and more pre-planned c-sections, overuse of medications before and during labor, and less care given to an expecting or laboring mother. I completely agree with needing to find a balance between the two extremes mentioned here. Women have been having babies for centuries, there is no need to over medicalize the event, or to withhold lifesaving technology and care because of location.