Clinical Causes

In the most recent WHO analysis of the global causes of maternal death, 73% of the deaths were considered to be due to direct obstetric causes. Of all direct and indirect deaths combined, 27% were due to hemorrhage, 14% to preeclampsia, 11% from puerperal sepsis, 8% from unsafe abortion, 3% from embolism, 3% from obstructed labor, and 7% from other direct causes combined. Virtually all these deaths could be avoided if the maternal and reproductive health services taken for granted in developed countries were available. The other 27% of maternal deaths worldwide are due to indirect causes, most of which result from preexisting underlying medical disorders exacerbated by the mother’s pregnant state.

Deaths from illnesses related to human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), regarded as indirect deaths, make a major contribution to maternal mortality globally and in some sub-Saharan countries cause more than half of all indirect deaths. In Botswana they account for 56%, and in South Africa and Namibia, the rates are 60%, rising to 67% in Swaziland. In four non-African countries—Ukraine, Bahamas, Thailand, and the Russian Federation—more than 20% of indirect deaths are due to HIV, with the majority being linked to intravenous (IV) drug use. A recent survey predicted that 12% of all deaths during pregnancy and up to 1 year after delivery will result from an HIV-positive pregnancy prevalence rate of 2% and that the MMR will increase to 50% in areas with an HIV-positive pregnancy prevalence rate of 15%.

In developed countries, indirect deaths predominate. The latest U.K. Confidential Enquiry into Maternal Deaths also reported that two thirds of the maternal deaths between the years 2009 and 2012 were due to indirect causes. The risk of a maternal death in the United Kingdom has significantly fallen over the past 10 years from already small numbers. The comparative U.K. MMR, calculated using WHO methods, is now 5.35 deaths per 10,000 live births. The majority of the reported indirect deaths were due to severe medical and mental health problems becoming complicated by pregnancy, such as preexisting cardiac disease, epilepsy, autoimmune disease, and suicide. These causes are now being bolstered by conditions adversely affected by poorer lifestyles such as acquired cardiac disease, hypertension, type 2 diabetes, liver disease, alcohol and drug dependency, and other disorders associated with obesity.

Health System Factors

A lack of health system planning and resources is one of the largest contributors to the continuing pandemic of maternal ill health and mortality. Many women receive no antenatal care at all, and the WHO estimates that only 38% of mothers in low-income countries receive the minimum four antenatal visits they recommend. Less than 50% of all women give birth accompanied by a skilled attendant, such as a midwife or doctor, and many lack access to facilities with staff and resources capable of providing basic emergency obstetric or newborn care ( Box 58-1 ) or to higher level services capable of dealing with serious complications or emergencies, such as undertaking life-saving cesarean delivery (CD) for mother or child.

A recent WHO study showed 54 countries that had CD rates lower than 10%, the minimum standard for safe motherhood services, and 69 had rates higher than 15%, all unacceptably high. In 2008, the conservative estimate of the overall rate for Brazil was 45.9%, and it was 30.3% for the United States, compared with 0.7% for Burkina Faso. The study also estimated that in 2008, 3.18 million additional CDs were needed, and 6.20 million unnecessary operations were performed worldwide. The cost of this global “excess” was estimated to amount to approximately $2.32 billion, whereas the cost of the “needed” CDs globally was approximately $432 million.

A critical lack of skilled staff, such as midwives and doctors, is also apparent. It is estimated that the world needs another 350,000 midwives, and doctors are also extremely scarce, especially in the unattractive, remote, and poorer areas of already resource-poor countries. To help address these shortages, task shifting—the transferring of skills and competencies to other trained individuals—is becoming increasingly commonplace. In some countries such as Mozambique, cadres of ancillary staff have been trained as clinical officers—nonphysician clinicians—to perform basic life-saving skills and procedures that include CD, and the results have been impressive.

An emerging issue is that of quality of care. To date, much of the global effort to reduce maternal mortality has focused on increasing access to care; however, the focus is now shifting toward improving and standardizing the variable quality of care that women receive from the health services they have been encouraged to attend. Clinical guidelines and protocols have been developed by the WHO and professional associations, and the use of maternal death reviews to learn lessons to improve care is also having a positive effect.

Vulnerability and Underlying Social Determinants

The underlying causes of maternal mortality are complex and multifactorial. For example, although a mother in a resource-poor country may technically be described as dying from a postpartum hemorrhage, the true underlying causes may be very different. She may have died because she had no care, or because she was unable to read the information leaflets about the warning signs and when or where to seek help. Care may have been available but beyond her reach physically or financially. Access to any form of transport in emergency situations is frequently problematic, especially at night. Furthermore, her husband or family members may have prevented her from attending care or lacked the money to pay the necessary bribes to secure her treatment. She may have refused to seek help because she has heard she would be slapped, shouted at, or treated disrespectfully in the health facility. Or she may have overcome all of these obstacles to reach a health care facility only to find poorly trained staff or no staff at all and no medicines, blood products, or equipment and no one capable of performing her life-saving operation. Added to which, she will probably have been in poor physical condition and suffering from anemia and other chronic health disorders. Thus the stated clinical factors surrounding a maternal death provide little or no indication of the underlying causes as to why the woman really died. Without understanding the wider “causes of the causes,” the barriers to safe maternity care cannot be identified and overcome. To help quantify these, it is common for those who work in the field of international women’s health to use the “three delays” model as a checklist to help identify the barriers pregnant women face . These barriers may be financial, physical, social, cultural, or medical and may be present in the family, the community, or the health care system. These are inextricably interlinked, and some examples are given in Table 58-2 .

“Causes of the Causes”

A recent report into inequalities in health outcomes in England, “Fair Society, Healthy Lives,” states that the “causes of the causes” are the circumstances and societies in which people are born, grow, live, work, and age. Social position, wealth, and education help determine each person’s health outcomes and life expectancy. It estimates that health care services contribute only one third to improvements in life expectancy and that improving life chances and removing inequalities contribute the remaining two thirds. If this is the case in a developed country, the ratio of inequalities in resource-poor countries must be far higher. Indeed, whether a pregnant woman lives or dies is a lottery that depends almost entirely on where she was born and lives and in what circumstances. Mothers who die are generally the least visible, most vulnerable, and poorest of the poor. Although urban poverty is an increasing problem, most maternal casualties tend to live in rural areas and lack both transport and access to skilled care in health facilities. They are more likely to be illiterate or poorly educated, undertake hard manual work, and find themselves almost permanently pregnant. In societies where social and economic deprivation is rife, so is the absence of laws to protect human rights and promote gender equality in places where those women with the lowest educational achievements are at greatest risk.

The lowly status of girls and women frequently means that they receive the last and least of the family food. General malnourishment, coupled with anemia and micronutrient deficiencies, leads to chronic ill health and multiple comorbidities such as malaria, HIV, or tuberculosis (TB). These women have little or no control over their health, being dependent on male or elder family members to decide whether they should seek care, even in emergencies. Many will become child brides, become pregnant, and be forced to give up any form of education. Female genital mutilation/cutting (FGM/C) is common and is associated with a higher incidence of obstructed labor, emergency cesarean delivery, fetal distress, obstetric fistula, and permanent perineal damage. All of these factors lead to complex pregnancies and higher rates of stillbirth and neonatal death.

Women’s Rights

“Imagine a world where all women enjoy their human rights. Take action to make it happen.” —1998 United Nations Campaign for Human Rights

A further, critically important reason why global efforts to reduce maternal mortality and morbidity have been slow is the low value that society, political, religious, community, and family leaders have placed on women’s lives. As the father of the Safe Motherhood movement, Professor Mahmoud Fathalla, famously said, “ Women are not dying of diseases we cannot treat … they are dying because societies have yet to decide that their lives are worth saving.”

In 1948, the Universal Declaration of Human Rights stated that “all human beings are born free and equal in dignity and rights.” The 1995 UN Beijing declaration on women’s rights reported that “the full implementation of the human rights of women and of the girl child is an inalienable, integral, and indivisible part of all human rights and fundamental freedoms.” By 2009, the UN Human Rights Council had acknowledged that preventable maternal mortality was a human rights violation, and health advocates started using human rights mechanisms to make governments honor their commitment to ensure access to services essential for reproductive health and well-being.

The right to health is a human right, and the health of a nation is determined by the health of its girls and women. Healthy women are more likely to fulfill their potential, nurture healthy families, and contribute to their local and national economies. Ellen Sirleaf Johnson argued that women’s socioeconomic empowerment is essential to achieve better health care outcomes, and she ended her 2011 Nobel Prize acceptance speech with a challenge: “Nations thrive when mothers survive, we must strive to keep them alive.”

The contribution made by mothers to society is far reaching, and countries that fail to protect and promote women’s rights have the worst economic, educational, maternal, and child health outcomes. The application of human rights shifts the understanding of maternal deaths as mere misfortunes that are acts of fate into injustices that the state is obliged to remedy. Using a human rights approach provides valuable tools to hold governments legally accountable to address the preventable causes of maternal mortality and to distribute resources and medicines essential for reproductive health, such as effective contraception and misoprostol to reduce postpartum hemorrhage. For example, when the Sri Lankan government introduced universal education and access to health care, maternal deaths declined significantly for little extra cost. Political will, literacy, and respect for the status and rights of women in society are key components for achieving sustainable health improvements.

Nearly 70 years after the Universal Declaration, many women still struggle to have their basic rights protected. As recently as 2013, objections were raised by certain countries and religious groups to a potential UN statement reaffirming women’s rights to education, contraceptive choices, family spacing, and the introduction of declarations against domestic violence, rape, child marriage, and FGM/C. Those who objected considered that upholding these human rights could destroy society by allowing a woman to travel, work, use contraception without her husband’s approval, and control her family’s spending. These may be extreme views, but there are still far too many countries that turn a blind eye to gender inequalities and violence that includes child marriage, rape, and FGM/C and who do not favor girls receiving primary, let alone secondary, education.

Human rights play an important role in the fight to improve the status of women because they embody a shared set of values that have been enshrined in law. Infringements can be litigated in countries that subscribe to them, but even countries that do not often appear to be sensitive to the charge that they are infringing the human rights of their population. Where the law hinders the use of contraception or does not allow induced abortion, health care professionals invariably find it easier to provide life-saving interventions if they can be reassured that they are protecting the woman’s right to life, to benefit from scientific advances, or to avoid discrimination.

Advocacy for women is an obligation for everyone engaged in reproductive health care. This means that all health care professionals need to know how to embed human rights principles into every aspect of their delivery of care. The International Federation of Obstetricians and Gynecologists (FIGO) women’s sexual and reproductive rights committee has developed a comprehensive teaching syllabus that can be adapted for use by a wide range of professionals. The clinical knowledge and practical skills required to deliver quality reproductive health care have been built around a core checklist of 10 health-related human rights. The result is a competency-based educational approach that simultaneously advocates for human rights and health by developing standards for performance and tools for training teachers and students in both the classroom and clinical settings. The teaching materials can be freely accessed and downloaded from the Global Library of Women’s Medicine (GLOWM). Experience from the teaching workshops with both laypersons and professional audiences confirms that this approach shifts the teaching of human rights and women’s reproductive health from a marginal to a mainstream position in the learning process for all health care professionals.