The news that wasn’t fit to print

Today 1,500 women died due to pregnancy or childbirth related causes.

That’s roughly one woman every minute.

Why isn’t this in newspaper headlines? Why has progress on Millennium Development Goal 5 on maternal mortality been uniquely stunted in Africa and other regions?

One answer to these questions is that simply put, the status of women and women’s health is not a priority. On a global level, it’s easy for those in high-income countries to feel removed from the issue. Indeed, 99% of maternal deaths occur in developing countries; over half in Africa [Fig 1].

(UNICEF, 2005)

Within these high mortality countries, gender norms surrounding women’s status and decision-making power have serious implications. Data from Ethiopia’s 2005 Demographic and Health Survey demonstrate a fascinating “dose-response” relationship between women’s status and her likelihood of accessing either antenatal, delivery or postnatal care from a health professional [Fig 2].

(DHS, 2005)

Women who participated in more decisions overall, who gave more reasons for refusing sexual intercourse, and less reasons to justify wife beating, all had higher access to these key services. A woman’s ability to seek care, and have received education on the recognition of danger signs, is crucial for reducing maternal mortality. This is related to the etiology of maternal deaths.

The majority of maternal deaths are preventable with interventions we’ve known for a long time. Deaths are also highly concentrated.

Causes of maternal mortality in Africa (Kinney et al, 2010).

Over half are from direct obstetric complications that occur around the time of childbirth (hemorrhage, hypertension, sepsis, and obstructed labor account for 64% of all maternal mortality) [Fig 3]. Correspondingly, over half of maternal mortality occurs within 24 hours of birth. Severe postpartum bleeding, the most common cause of death, can kill a healthy woman within two hours if not properly attended.

Thus, reducing maternal mortality means ensuring women receive the right care at the right time. The literature conceptualizes three main delays that can occur to undermine this:

  • Delay 1: Delay in problem recognition and care-seeking (note: lack of decision-making power to seek care is an issue here)
  • Delay 2: Delay in reaching a health facility (e.g. lack of transportation or financial means)
  • Delay 3: Delay in receiving prompt and appropriate care at the facility

In Oromiya region, Ethiopia, where my current research is focused, virtually all women (95.2%) deliver at home. Only 5% of births are delivered by a skilled health professional, and roughly a third had an untrained traditional birth attendant as the most qualified person present, with the vast majority (~60%) with a family member or relative as the most qualified person present. About 5% of births occur with nobody present. This is partly due to extreme health worker shortages. Ethiopia has1 physician per 22,198 people—and most of these are concentrated within Addis Ababa and other urban areas. In addition, many women do not perceive a need for trained birth attendants, nor the need for early initiation of antenatal care or other pregnancy-related care. And in fact, there are many substantial missed opportunities with these services. Only 26% of women who received antenatal care were informed of signs of pregnancy complications. Furthermore, only about half of women who received their first tetanus toxoid (TT) injection were instructed on the need for additional vaccinations. Consequently, only a third of Oromiyan women have sufficient doses of TT to confer protection at birth. Finally, even if women do deliver in a health facility, only 25% of these have a functioning delivery room, and even fewer hospitals are capable of providing comprehensive obstetric care (performance of caesarean sections and blood transfusions).

Thus, overcoming the three delays not only requires behavior change and education within communities, but also skilled health providers, adequate supplies and equipment, and integrated referral systems. In other words: social change and a functioning health system.

It’s perhaps no surprise why reducing maternal mortality is so difficult. This leads to an interesting realization however, which is that maternal mortality indicators are a way to capture progress on the harder-to-measure realms of gender equity and health systems strengthening.

The implications of maternal deaths on child survival and societal well-being are vast and long-lasting. Let’s keep maternal health a priority. Every minute counts.

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