Improving Global Maternal Health: Challenges and Opportunities

Key Abbreviations

Acquired immune deficiency syndrome AIDS

Cesarean delivery CD

Contraceptive prevalence rate CPR

Female genital mutilation/cutting FGM/C

Global Library of Women’s Medicine GLOWM

Gross national income GNI

Human immunodeficiency virus HIV

International Conference on Population and Development ICPD

International Federation of Obstetricians and Gynecologists FIGO

Intrauterine device IUD

Long-acting reversible contraception LARC

Low-income country LIC

Millennium development goal MDG

Middle-income country MIC

Maternal mortality ratio MMR

Nongovernmental organization NGO

Postpartum hemorrhage PPH

Sexually transmitted infection STI

Traditional birth attendant TBA

Tuberculosis TB

World Health Organization WHO

United Nations UN

Maternal and Reproductive Health

This chapter can only touch the surface of the complex issues relating to the continuing yet avoidable tragedy of maternal deaths worldwide. However, for those readers for whom it provides the impetus for more in-depth study, many key documents and papers are contained within its references. First, we offer a brief description of the main clinical, health system, and wider social causes and key actions for the prevention of deaths and obstetric complications, particularly in resource-poor countries, and conclude with a summary of the steps that need to be taken at individual, professional, facility, and health system levels and nationally and internationally to help reduce these needless deaths. The section after that provides clinical details on the challenges of preventing, identifying, and managing the main obstetric complications of pregnancy in resource-poor settings, and the final section provides some practical tips for anyone considering working abroad for longer or shorter periods of time.

Maternal Health and the Burden of Death and Disability

“Many Births Mean Many Burials” —Kenyan Proverb

Every year worldwide, around 290,000 mothers and 3 million babies die at the time of birth, and another 3 million infants are stillborn. Despite recent initiatives, which in some countries have resulted in declines in maternal death rates over the past few years, too little has happened too late. The fact is that the main causes of maternal death and preventive or remediable interventions have been well known for many years, and nearly all of these vulnerable mothers could be saved at little extra cost. Lives would be saved if women had a choice about becoming pregnant, and once pregnant, if they and their babies had access to essential health services that provide evidence-based, technologically appropriate, and affordable interventions even in the poorest countries of the world. This in turn depends on the availability of resources and the recognition and enforcement of the human rights of girls and women. For example, a recent United Nations (UN) report estimated that if all women who actually wanted to avoid pregnancy were able to access and use an effective method of contraception, the number of unintended pregnancies would drop by 70%, and the number of unsafe abortions would drop by 74%. Further, if these women’s contraceptive needs were met, and if all pregnant women and their newborn babies received the basic standards of maternity care recommended by the World Health Organization (WHO), the number of maternal deaths would fall by two thirds—from 290,000 down to 96,000—and the number of newborn deaths would fall by more than three quarters, down to 660,000.

Deaths are merely the tip of the iceberg. Globally it is estimated that over 300 million women are living with short- or long-term pregnancy-related complications with around 20 million new cases occurring each year. These figures do not reflect other additional yet poorly recognized burdens. In most countries postnatal depression, suicide from puerperal psychosis, and other mental health issues are not even acknowledged as pregnancy-related problems, and the stories of legions of women dying or suffering from these debilitating conditions remain untold.

Babies are affected by their mother’s health in pregnancy and birth, and added to the 6 million who die before or just after birth, many more millions are left motherless and less able to thrive. The risk of death for existing children under 5 is doubled if their mother dies in childbirth, which is particularly challenging for girls.

Every maternal death or long-term complication is not only a tragedy for the mother, her partner, and her surviving children, it is also an economic loss to her family, community, and society. Saving mothers lives is also crucial to the wider economy; for example, in Nigeria during 2005, it was estimated that maternal deaths alone led to around $102 million in lost productivity.

A Place Between Life and Death

In developed countries, pregnancy is not generally considered as dangerous, and childbirth is usually regarded as a joyful and positive life-changing event. However, these 11 million births account for only 8% of the annual deliveries worldwide. The same cannot be assumed for the 92% of mothers, some 124,000 million women, living in less developed areas of the world. Of these, approximately 800 will die and 16,000 will suffer severe and long-lasting complications every day. Additionally, every day, nearly 8000 babies will die around the time of birth, and another 7000 will be stillborn. Overall, this burden of maternal and neonatal mortality, including stillbirths, accounts for around 15,800 deaths each day, or 10 lives lost every minute .

In Chichewa, the national language of Malawi, the word pakati refers to pregnancy. Its literal translation means “in the middle between life and death.” In other African countries, it is common to hear women in labor using euphemisms such as “I am going to the river to fetch water; I may not come back,” or childbirth is described as “slipping on a banana skin at the edge of a cliff with no safety net.”

These concerns are all too real for many women, and “a place between life and death” is an accurate description of the 9 months of anxiety and fear that accompany pregnancy and delivery. The World Bank classifies every economy as low, middle, or high income; it uses gross national income (GNI) per capita because GNI is considered to be the single best indicator of economic capacity and progress. Low-income and middle-income economies are collectively referred to as developing economies. For the 11 million mothers in high-income countries (HICs), access to quality antenatal, intrapartum, and postnatal care for both mothers and babies is readily available. Another 34 million women will deliver in middle-income countries (MICs), where hospital facilities with variable quality of care or resources such as staff, blood, drugs, or high dependency units may be available. However, for the 90 million mothers in low-income countries (LICs), the situation can be very different, with little or no access to even basic health care, which places the health of both mother and baby at significantly higher risk. The film “Why Did Mrs. X Die: Retold” is available online in several languages (, and it provides a simple introduction.

Where Mothers Die

Of all the maternal deaths that occur, 99% are in low and middle-income countries, the same as for newborns. The WHO defines the maternal mortality ratio (MMR) as the number of direct and indirect maternal deaths per 100,000 live births during pregnancy or up to and including 42 days after the end of pregnancy. The latest UN estimates for 2013 are that the overall global MMR is 210 deaths per 100,000 live births, with an even higher figure (230) for developing regions (LICs and MICs) compared with 12 for developed regions. The highest regional MMR is 520 for sub-Saharan Africa, followed by 190 for both the Caribbean and Oceania, 170 for Southern Asia (which drops to 140 if India is excluded), 77 for Latin America, 60 for North Africa, and 39 for Central Asia. However, these figures hide wide intercountry and intracountry variations. Overall, Sierra Leone is estimated to have the highest MMR (1100), followed by Chad (980), the Central African Republic (880), and Somalia (850). Ten other African countries have MMRs higher than 500 per 100,000 live births. Due to the sheer weight of its population, the annual deaths of 50,000 mothers in India account for 17% of the global total. This is despite the country having made significant progress in recent years with a concerted effort at national, state, and local levels: the Indian MMR fell from 600 in 1990 to 200 in 2010.

Adolescent Girls and Lifetime Risk of Maternal Death

Ending child marriage is a public health priority. Apart from taking away their childhood, young pregnant girls are more likely to die and are at greater risk of complications. Those under the age of 15 are five times more likely to die of a pregnancy-related cause than women in their twenties. Every year, 3 million undergo unsafe abortions. Maternal death is now the leading cause of death for young girls in developing countries, with 15% percent of all deaths worldwide occurring among adolescents. Compared with mothers aged 20 to 24 years, girls aged between 10 and 19 years have higher risks of obstructed labor, eclampsia, puerperal sepsis, systemic infections, and preterm deliveries and require more cesarean deliveries. Their babies also fare worse as a result.

In developing countries, a 15-year-old girl faces a 1 : 160 risk of dying from a pregnancy-related complication during her lifetime, and this rises to an average risk of 1 : 38 for those who live in sub-Saharan Africa. The average risk in the most developed countries is 1 : 3750. In the very worst countries to be born a girl—such as Chad, Niger, and Côte d’Ivoire—the lifetime risk is still between 1 : 15 and 1 : 29 despite the fact that these figures have actually been halved over the past 10 years. Even in the developed world, wide variations are seen within a country depending on who the mothers are, where they live, and their social circumstances. In the United Kingdom, for example, vulnerable unemployed women are 10 times more likely to die or suffer complications than women in families where at least one member is employed.

United States

The WHO estimated the overall MMR for the United States to be 28 per 100,000 live births in 2013, which is threefold greater than in Western Europe and Australasia. Indeed, the United States is one of the few countries whose MMR has increased, rather than decreased, in recent years. This may be due to a steady rise in the number of women with advanced maternal age, chronic medical conditions, and obesity coupled with an increasing number of medical interventions, not all of which may be necessary. Recent patient safety research demonstrates that where consistent protocols for diagnosis, management, consultation, or referral of complicated cases are lacking, less optimal maternal outcomes may result.

In the United States, as in many Western countries, the most common obstetric conditions resulting in severe maternal morbidity or mortality are obstetric hemorrhage, severe preeclampsia, and venous thromboembolism. Recent case reviews have highlighted that a significant proportion of the morbidity and mortality from these conditions are due to missed opportunities to improve maternal outcomes. A major challenge is to identify those women who need specialist care at an early stage, without eliminating the category of lower-risk cases. To address this complex problem, a multidisciplinary group of senior health care and birth facility leaders to review and amend current recommendations and plan a national approach to implement improved strategies has recently been convened as the U.S. National Partnership for Maternal Safety.

Mothers Who Survive: Severe Maternal Morbidity

Whereas global maternal deaths may have been neglected until relatively recently, women who suffer from severe maternal morbidity and its long-term sequelae have fared even worse. It is estimated that 1.1 million of the annual total of 136 million births are complicated by a severe maternal “near-miss” event, after which the mother survived either by chance or following high-quality medical care . A further 9.5 million women suffer more manageable complications that are still very severe, and 20 million mothers suffer longer-term complications each year. These are conservative estimates.

Whatever the death-to-disability ratio, as with maternal deaths, the numbers will always be too high, and the underlying causes are disturbingly similar. Hence, reducing the risk factors for death will help to decrease the number of significant obstetric complications. Table 58-1 estimates the overall numbers and case fatality rates for the five major global direct obstetric complications of pregnancy and the overall numbers of women affected. Direct maternal deaths are those that result from obstetric complications of the pregnancy state (pregnancy, labor, and the puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above. Indirect obstetric deaths are those that result from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes but was aggravated by physiologic effects of pregnancy. Coincidental maternal deaths are those from unrelated causes that happen to occur in pregnancy or the puerperium. Late maternal deaths include the death of a woman from direct or indirect obstetric causes more than 42 days but less than 1 year after termination of pregnancy.

TABLE 58-1


Hemorrhage 10.5 13,795,000 1.0 132,000 28%
Sepsis 4.4 5,768,000 1.3 79,000 16%
Preeclampsia, eclampsia 3.2 4,152,000 1.7 63,000 13%
Obstructed labor 4.6 6,038,000 0.7 42,000 9%
Abortion 14.8 19,340,000 0.3 69,000 15%

Modified from AbouZahr C. Global burden of maternal death. In British Medical Bulletin. Pregnancy: Reducing Maternal Death and Disability. British Council. Oxford University Press; 2003, pp. 1-13.

As stated by Zacharin, “In an unequal world, these women are the most unequal among unequals.” Of all the long-term morbidities arising from childbirth, an obstetric fistula is one of the worst. It is estimated that in sub-Saharan Africa and in parts of Asia, between 654,000 to 2 million young women live, usually in isolation and shame, with untreated obstetric fistulae; the annual incidence is 50,000 to 100,000 new cases.

Obstetric fistulae are highly stigmatizing, and affected women often become social outcasts. The constant leakage of urine and or fecal matter makes it difficult for them to remain clean, especially in areas with limited access to water, and they most likely will never have children. It is hard to find work; and having failed in their primary objective to have children, they offer little, if any, economic advantage to their families. As a result they are frequently rejected and cast out. The growth in training local surgeons in techniques for simple repair and the ever increasing number of specialist fistula repair centers who also train local staff is slowly helping restore function, fertility, and dignity to these women—but the services available are still few and far between. This is discussed in more depth in the section “ Obstructed Labor and Obstetric Fistula .”

Babies Who Die

Mothers and their babies are a dyad, inextricably linked, yet all too often the newborn is overlooked when considering policies to reduce the impact of maternal ill health or death. Around half of the annual 2.6 million stillbirths and 2.9 million deaths in the neonatal period, the first month of life, occur as a result of maternal complications during pregnancy or delivery. Thus improving maternal care helps more babies survive, and they survive in better condition, which provides a healthier start to life.

Most neonatal deaths (73%) occur during the first week of life with around 36% in the first 24 hours. The major causes are complications that arise from preterm birth (36%), intrapartum asphyxia (23%), and neonatal infections such as sepsis, meningitis, and pneumonia, which together contribute 23%. Two thirds of newborn deaths could be prevented if skilled health workers performed effective interventions at birth and during the first week of life.

Labor and the 24 hours surrounding birth are the riskiest times for mother and baby, with 46% of maternal and 40% of neonatal deaths and stillbirths occurring during this period. This fuels the repeated call for more skilled birth attendants to assist at delivery, which should take place in a clean and well-equipped unit with working transport links to more comprehensive facilities capable of managing emergency complications for both mother and baby.

Why Mothers Die

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.

Box 58-1

Basic Emergency Obstetric Newborn Care

Basic emergency obstetric and newborn care is critical to reducing maternal and neonatal death. This care, which can be provided with skilled staff in large or small health centers, includes the capabilities for:

  • Administering antibiotics, uterotonic drugs (oxytocin), and anticonvulsants (magnesium sulfate)

  • Manual removal of the placenta

  • Removal of retained products of conception following miscarriage or abortion

  • Assisted vaginal delivery, preferably with vacuum extractor

  • Basic neonatal resuscitation care

Comprehensive emergency obstetric and newborn care , typically delivered in hospitals, includes all the basic functions above, plus capabilities for:

  • Performing cesarean delivery

  • Safe blood transfusion

  • Provision of care to sick and low-birthweight newborns, including resuscitation

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 .

TABLE 58-2


Delay in seeking care

  • Traditional beliefs and practices, use of traditional birth attendants

  • Lack of education and understanding of need for care or warning signs

  • Mother is not decision maker

  • Mother has no money and no control over decisions affecting her life

  • Religious custom and practice

Delay in arriving at a place of care

  • No transport

  • No money

  • Unofficial bribes

  • Services patchy or too far away

  • Concerns about physical abuse by staff in labor

  • Poor reputation of facilities as “places where women and babies die”

Delay in providing appropriate quality care

  • Facilities not equipped to provide basic and/or emergency obstetric care

  • Lack of suitably trained staff

  • Poor clinical practice

  • Little or no use of evidence-based protocols and guidelines

  • Physical and verbal abuse of women in labor

  • Lack of blood, medicines, essential equipment, and operating theatres

  • Frankly harmful care

  • Intermittent electricity, water, and so on

Modified from Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994:1091-1110.

“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.

Sexual and Reproductive Health

The lack of universal access to basic sexual and reproductive health services is one of the most significant barriers to reducing maternal morbidity and mortality globally. As stated at the very start of this chapter, but worth repeating here, a recent report estimated that if all women wanting to avoid pregnancy used an effective method of contraception, the number of unintended pregnancies would drop by 70%, and unsafe abortions would drop by 74%. If these women’s contraceptive needs were met, the number of maternal deaths would fall by two thirds, and newborn deaths would decline by more than three quarters, and the transmission of HIV from mothers to newborns would also be virtually eliminated. Furthermore, it was estimated that contraceptive use averted 272,040 maternal deaths in 2008 and that meeting unmet need for contraception could prevent an additional 104,000 deaths per year, thus preventing a further 29% of maternal mortality. This further reduction by about one third if the unmet need for contraception were met is similar to estimates reported by others, and it underscores the critical role that access to effective contraception plays in preventing maternal mortality and morbidity.

Sexual and reproductive health was formally defined at the 1994 International Conference on Population and Development (ICPD). At its core is the promotion of healthy, voluntary, and safe sexual and reproductive choices for individuals and couples, including decisions about if, when, and with whom to have children. It encompasses highly sensitive and important issues such as sexuality, pregnancy prevention and abortion, gender discrimination, and male/female power relations. Its full attainment depends on the protection of human and reproductive rights. The conference also adopted the goal of ensuring universal access to sexual and reproductive health as part of its framework for a broad set of development objectives and Millennium Development Goals (MDGs) and set very similar objectives in their Target 5:B. Despite these initiatives, an estimated 85 million unintended pregnancies occurred in 2012.

Unintended Pregnancy

An unintended pregnancy is one that is mistimed, unplanned, or unwanted at the time of conception, and such pregnancies are associated with an array of negative health, economic, social, and psychological outcomes for women and children. In 2012, the global unintended pregnancy rate was 53 per 1000 women aged 15 to 44, with the highest rates in Eastern and Middle Africa (108 each) and the lowest in Western Europe (27). Of these 85 million unintended pregnancies, 50% will end in termination, which corresponds to about 1 in 5 of all pregnancies and contributes to the pandemic of unsafe abortion. A further 13% will end in miscarriage, and 38% will result in an unplanned birth. Four out of five pregnancies in the developing world occur among women with no access to modern effective contraception, but even in settings where contraceptive use is comparatively high, unintended pregnancies may still occur when the available contraceptive method fails or because of poor adherence.


Voluntary access to family planning—especially modern, effective contraceptive methods for women and men—is crucial to directly improving health outcomes and is positively associated with improvements in educational and economic status. The health benefits include sizable reductions in maternal, newborn, and child morbidity and mortality as well as deaths and complications that arise from unsafe abortion. At the household level, improved access to family planning services leads to substantial improvements in women’s earnings and children’s schooling. Nationally, higher levels of uptake correlate with lower fertility rates, which enhance economic growth. Conversely, high levels of unwanted fertility correlate with poverty and inequality.

Barriers to contraceptive usage can also be categorized according to the three-delay model described earlier and can occur at the client, health care provider, and health systems level. The most frequently cited reasons for nonuse among women is poor understanding of their risk for pregnancy, concerns about possible side effects, infrequent sexual activity, service fees, or opposition; in the latter, desires of a male partner or religious or cultural reasons are cited. Married women may have little control over contraceptive decision making, which is particularly important when partners differ in their childbearing preferences. Unmarried women frequently have to face strong stigma from judgmental providers if they are sexually active, which in turn reduces these women’s ability to obtain needed services. At the provider level, barriers include lack of knowledge or skills, motivation, and bias for or against certain methods, such as intrauterine devices (IUDs). Limiting the provision by certain provider types also blocks uptake: for example, only allowing doctors to insert IUDs or imposing non–evidence-based restrictions on when a method can be started, such as commencing only at the time of menses. Common health system barriers include inadequate human and financial resources and a failure to integrate family planning with other core services such as maternity and child health clinics, delivery, postnatal or postabortion care, and HIV services. Access may also be limited through geographic constraints and lack of equipment and supplies. Shortages of supplies are very common, especially in rural areas. In addition to overcoming provider bias, lack of competency, and health systems issues, most low-resource settings are still in need of educational interventions to increase awareness and understanding for the community as a whole, thereby reducing many of the existing barriers to effective contraceptive use.

Contraceptive prevalence is typically defined as the percentage of women who are currently using, or whose sexual partner is currently using, at least one method of contraception regardless of the method used; usually, it is reported for married or in-union women (women in a stable sexual relationship) aged 15 to 49. In recent decades, general increases in contraceptive prevalence rates (CPRs) have been seen in most areas of the world, and globally, they increased from 53% in 1990 to 57% to 64% in 2011 through 2012. However, CPRs remain extremely low in parts of Africa with regional estimates of 32%, 19%, and 15% in Eastern, Middle, and Western Africa, respectively, giving a rate of 24% to 30% for Africa overall. Wide intercountry variations are also apparent: for example, since 1990, progress in contraceptive use has been made in Rwanda (18% to 50%), Malawi (12% to 45%), and Tanzania (11% to 34%); yet in Sierra Leone and Nigeria, the CPRs for 2010 were 6.7% and 8.6%, respectively. In Southern Africa, rates are now relatively high at 62%, having risen from 47%, and in Southern Asia, rates have risen from 36% to 50% in India and from 34% to 61% in Bangladesh; in addition, substantial gains have been made in Latin America, where the regional CPR is now 73%. Although high and most stable in Europe and North America (72% to 78%), the rates are highest in East Asia, largely attributable to China (83%). Nevertheless, the overall global CPR remains low, and this is a serious obstacle to further improving women’s health.

Unmet need for family planning is typically defined as the percentage of women who want to stop or delay childbearing but who are not using any method of contraception to prevent pregnancy. A more useful definition regards both women who use no method or women who use traditional methods as having an unmet need for modern methods, not only because traditional methods have high use-failure rates, but also because, although some women using traditional methods might choose to use these methods, such choices often imply that women perceive other options to be unavailable, or are not fully informed of contraceptive options.

The unmet need for contraception is unacceptably high. Globally, 222 million women who would prefer and are trying to limit or space their pregnancies are not using contraception. Around three-quarters of these women live in the world’s poorest countries, and the unmet need remains greatest in sub-Saharan Africa (60%) and West and South Asia (50% and 34%, respectively) with disproportionately high levels among illiterate, poor, adolescent, and rural women.

The postpartum period is crucially important for contraceptive intervention because rapid repeat pregnancies are associated with poor maternal and infant outcomes. An analysis of data from 27 countries found that 95% of women who were 12 or fewer months postpartum did not want another birth within 2 years, yet 65% of them were not using contraception. Similarly, although most women being treated for complications of induced or spontaneous abortion are in need of effective contraception, data from 17 low-resource countries show that only 1 in 4 of these women were discharged from care with a method in place.

Contraceptive Methods

The type of contraceptive method used is also variable, but choice is critical in relation to efficacy and continued usage, particularly in areas where women find it difficult to attend clinics, or where the service is unavailable or limited by shortages and failure of supplies. Traditional contraceptive techniques such as withdrawal and fertility awareness (natural family planning) are the least effective. The emphasis should be on enabling women and their partners to have access to a wide range of the most effective modern methods. WHO classifies contraceptive methods into effectiveness tiers, which are described in Table 58-3 . The effectiveness of the method is critically important for reducing the risk of unintended pregnancy and can be measured either with “perfect use,” when the method is used correctly and consistently as directed, or with “typical use,” which reflects real-world actual use, including inconsistent and incorrect use.

Mar 31, 2019 | Posted by in OBSTETRICS | Comments Off on Improving Global Maternal Health: Challenges and Opportunities
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