NEWSLETTER January 2024
Deaths of Women in Pregnancy and Childbirth: Easily Preventable, but Alarmingly Persistent
Pregnancy and childbirth continue to kill women around the world, even though these deaths are largely preventable. This is unacceptable and infuriating.
This is the first of a two-part newsletter to understand what is going on and what we can all do about it!
What is maternal mortality?
The World Health Organization defines maternal mortality as “female deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site [i.e., ectopic pregnancies are included] of the pregnancy.” (I note that this definition doesn’t account for the fact that some pregnant persons identify as male or non-binary rather than female, yet are capable of gestation and childbirth).
Maternal mortality is represented by the maternal mortality ratio (MMR), that is, the number of maternal deaths per 100,000 live births. In countries with good vital statistics or reliable household surveys, recorded deaths are used to calculate the MMR. In those with weak statistical systems, estimations of maternal mortality are made by UN agencies and the World Bank Group using fertility data and other information, such as the percentage of births assisted by a skilled healthcare provider.
Has maternal mortality improved?
Since the 1980s, worldwide maternal mortality has been cut roughly in half. The global maternal mortality ratio was estimated to be 441 maternal deaths per 100,000 live births in 1985. It fell to 223 per 100,000 live births in 2020. That’s a significant improvement.
But that means that, in 2020, about 287,000 women still died during and following pregnancy and childbirth. That’s 786 women a day—the equivalent of three jet planes full of women crashing every day. Those persistently high numbers are unacceptable, because almost all maternal deaths are preventable.
What are the medical causes of women’s deaths in pregnancy and childbirth?
The following five major medical complications account for nearly 75% of all maternal deaths:
- Severe bleeding, mostly after childbirth (hemorrhage);
- Systemic infections after childbirth or an unsafe abortion (sepsis);
- Very high blood pressure during pregnancy and after childbirth (pre-eclampsia and eclampsia);
- Obstructed labor and other complications during childbirth; and
- Unsafe abortions, which can result in hemorrhage, sepsis, and lethal injuries.
Since so many women continue to die, how do we know that most maternal deaths are in fact preventable?
Because a number of countries have been able to reduce maternal deaths significantly, and not only rich countries. For example, Costa Rica, Thailand, Sri Lanka, Malaysia, Egypt and Turkey all have what UNICEF defines as “very low” maternal mortality ratios, i.e., fewer than 100 maternal deaths per 100,000 live births. In fact, all these countries have achieved fewer than 30 maternal deaths per 100,000 live births. By contrast, Chad, Nigeria and South Sudan fare the worst, with “extremely high” MMRs, reaching over 1,000 deaths per 100,000 live births.
What can be done to prevent and stop maternal deaths?
The solutions have been well known for decades. They were comprehensively catalogued at a global meeting of the World Health Organization’s Safe Motherhood Initiative in Colombo, Sri Lanka back in 1997. They require the following primary healthcare infrastructure, none of which is extraordinary or costly:
- Antenatal care: to identify any emerging condition during pregnancy and to administer (or refer for) treatment, such as magnesium sulfate for maternal high blood pressure, or an abortion to address an unwanted or non-viable pregnancy;
- Skilled birth attendants such as nurse midwives: to verify that labor is progressing normally and to transfer the pregnant person to higher levels of care, should complications arise (which happens in about 10–15% of deliveries);
- Emergency Obstetric Care (EOC): readily available, staffed and equipped emergency care to address these complications, to offer blood transfusions, oxytocics (to stop post-birth bleeding), antibiotics, pain management, C-sections and abortion care;
- Postnatal care: to address any postpartum complications (such as depression) and offer access to other health services, including contraception.
Single interventions alone (e.g., antenatal care only) do not reduce maternal deaths. The full panoply of healthcare measures listed above must be in place to see meaningful improvement. A favorable legal and policy environment is also essential; for example, abortion services must be allowed in law, and women must be able to consent to treatment without a male guardian or husband present.
A functioning primary healthcare system is not only beneficial to pregnant persons and babies. It is a necessity for all people to achieve their highest attainable standard of health. For example, a staffed and equipped emergency room can help many patients other than women in childbirth. Investing in maternal healthcare thus benefits everyone, as concluded by the UN Millennium Task Force on Child and Maternal Health back in 2005.
How much greater is the risk of maternal mortality for women in poor countries?
Almost 95% of all maternal deaths occurred in low and lower middle-income countries in 2020. Sub-Saharan Africa and Southern Asia fared the worst. Sub-Saharan Africa alone accounted for about 70% of worldwide maternal deaths (202,000) while Southern Asia accounted for about 16% (47,000).
The high number of maternal deaths in some areas of the world reflects inequalities in access to quality primary healthcare services and often highlights the gap between rich countries and poor ones. The average MMR in low-income countries in 2020 was 430 deaths/100,000 live births versus 12 deaths/100,000 live births in the highest income countries. But there are also significant gaps between rich and poor, and majority and minority or marginalized populations within these countries.
Is preventing maternal mortality too expensive for poor countries?
No. As noted above, a number of lower income countries have significantly reduced maternal deaths. For example, Sri Lanka and Malaysia have achieved very low maternal mortality rates by spending 0.23% and 0.4% of their gross domestic product (GDP) respectively, or about 12% of their total spending on health. That is affordable.
Unfortunately, many countries have NOT made saving women’s lives in pregnancy and childbirth a priority. Professor Mahmoud Fathalla, an eminent Egyptian obstetrician-gynecologist who devoted his career to ending maternal mortality, famously said: “Women are not dying because of diseases we cannot prevent or treat. They are still dying because societies have yet to decide their lives are worth saving.”
Unhelpfully, international finance institutions such as the International Monetary Fund have, since the 1980s, made their financial aid to poor countries conditional on austerity measures (“structural adjustment)” that have hurt the health and education sectors.
How is the US doing when it comes to maternal mortality?
The US is, shockingly, the only rich country where maternal deaths are increasing. In fact, the US MMR has been on the rise since the early 2000s, after remaining below 8 maternal deaths/100,000 live births from 1982 to 1999. Other industrialized countries have MMRs that remain consistently below the 12 maternal deaths/100,000 live births range. In fact, in 2020, according to the World Health Organization (WHO), Canada was at 11, Sweden at 5, France at 8, the United Kingdom at 10, Italy at 5 and Japan at 4, making maternal death a rare event. By contrast, in 2020, the US’s MMR was at 21/100,000, according to the WHO.
The US government’s Centers for Disease Control and Prevention (CDC), whose figures are slightly different than those of the WHO, reported 23.8 maternal deaths per 100,000 live births in 2020. And it’s rapidly getting worse, with 32.9 maternal deaths per 100,000 live births in 2021.
The glaring and growing disparity between Black and white women in the US appears to account for most of these worsening numbers. In 2021, the MMR for Black women reached a whopping 69.9 deaths per 100,000 live births—up from 55.3 in 2020, 44 in 2019, and 37.3 in 2018. Black women in the US are now three times more likely to die in pregnancy and childbirth than white women. The Yale School of Medicine attributes this shocking disparity to a number of factors connected to systemic racism: overt and implicit bias from healthcare providers, who have been shown to routinely ignore Black women’s reports of symptoms and requests for help, and the “allostatic load,” defined as the cumulative physiological effects of chronic stress on Black women due to racism. Unaffordable or inaccessible primary healthcare compound this tragic situation.
Restrictive abortion laws, now in place in close to 20 US states, only worsen the situation by denying pregnant persons the obstetric care they need, including emergency care. Maternal deaths have consistently been significantly higher in US states with restrictive abortion laws than in states where access to abortion is guaranteed by law. In 2020, according to the Centers for Disease Control and Prevention, the MMR in restrictive states climbed to 28.8 versus 17.8 in states with guaranteed access. This was true even before the Supreme Court’s Dobbs decision, which overturned the national right to abortion in June 2022.
Moreover, restrictive abortion laws increase the risk that pregnant persons will resort to unsafe methods of abortion, although abortion pills, which are very safe, are changing that—as long as pregnant persons can access abortion pills in conjunction with accurate information on how to use them.
What is the target for reducing maternal mortality worldwide? Are we on track?
The Sustainable Development Goals, which all governments adopted in 2015, aim to reduce the global maternal mortality ratio to fewer than 70 maternal deaths per 100,000 live births by 2030.
With only six years to go, the world is not on track to achieve this goal. In fact, maternal mortality ratios rose or stayed the same in nearly all regions of the world in 2020, according to the WHO. COVID infections in pregnancy remain particularly dangerous. Armed conflict, forced migration and displacement, and the persistent lack of government investment in primary healthcare/universal health coverage also harm maternal health.
In my next newsletter, I’ll be talking to the experts at the World Health Organization to go into greater depth on the causes and solutions, and to hear about new developments. In the meantime, we must demand universal health coverage—yes, for US folks, that’s Medicare for All!—as well as dedicated investments in maternal health, and unrestricted access to abortion if we want pregnancy and childbirth to be the joyous events they should be, rather than the tragedies they remain for too many around the world.
In health and solidarity,
FG