I. Preventable Maternal Mortality and Morbidity: A Global Public Health Emergency

[Maternal mortality is] a measure of mortality that can be dramatically, rapidly, and consistently decreased-almost to the point of negligibility-if the appropriate actions are taken.

- United Nations Millennium Project Task Force on Child Health and Maternal Health, 2005.

Pregnancy is not a disease or illness. Yet more than half a million women and girls die every year because of pregnancy, childbirth, and unsafe abortions.[14] Health experts determine that about 75 percent of these maternal deaths are preventable. Year after year women die preventable deaths merely because they do not have access to appropriate health interventions.[15]

Pregnancy and childbirth also leave millions of women and girls with short- or long-term injuries, infections, or disabilities (maternal morbidities). For every maternal death there are about 20-30 cases of maternal morbidity.[16]Between 50,000 and 100,000 new incidents of obstetric fistulae (tissue damage between the vagina and the bladder or rectum leading to incontinence) are detected annually.[17] Other long-term morbidities include uterine prolapse (weakened muscles after childbirth leading to displacement of uterus), infertility, and depression; short-term complications include hemorrhage, convulsions, cervical tears, shock, and fever.[18]

This has implications not only for women's reproductive health overall. Differences in levels of preventable maternal mortality and morbidity are strong indicators of other disparities, in particular the unequal access to quality health care, both between women in developed and developing countries and among women in the same country. Nearly 99 percent of all maternal deaths and morbidities occur in developing countries, particularly sub-Saharan Africa and South Asia.[19] The difference between Ireland and Sierra Leone illustrates this disparity: in Ireland 1 death occurs per 100,000 live births compared with Sierra Leone's 5,400 deaths. In Niger, one in every eight 15-year-old girls is expected to eventually die of a maternal cause. In contrast, 1 in 47,600 15-year-olds will die in Ireland.  

Causes and the Three Delays

Globally, approximately 80 percent of all maternal deaths are estimated to be caused by direct obstetric causes including hemorrhage, sepsis (severe infection spreading through the bloodstream), eclampsia (pregnancy complication characterized by seizures or coma), unsafe abortions, and prolonged or obstructed labor.[20] Other indirect causes include malaria, tuberculosis, and HIV/AIDS.[21] In countries with high rates of HIV, malaria, or tuberculosis, the proportion of deaths due to such causes may be higher.[22]

Medical causes explain just part of the story. Typically, a maternal death marks the tragic ending of an already complex story with different elements-socio-economic, cultural, and medical-operating at different levels-individual, household, community, and health system-related. Factors contributing to maternal death include early marriage, women's poor control over access to and use of contraceptives of their choice, husbands or mothers-in-law dictating women's care-seeking behavior, overall poor health including poor nutrition, poverty, lack of health education and awareness, domestic violence, and poor access to affordable quality health care, including basic and comprehensive emergency obstetric services.[23]

Health experts typically analyze these myriad circumstances using the "three delays model." In this model the reasons for delay in seeking and utilizing appropriate health care are broken down into three segments-the first being the delay in seeking professional health care, followed by the delay in reaching the appropriate health facility, and lastly, the delay in receiving care.

Some healthcare providers tend to unjustifiably lay all the blame for delay on pregnant women and their families for their uneducated or unresponsive behavior. But the delay in people's decisions to seek care is often due to their perceptions of systemic shortcomings and mistrust in health facilities.[24] Many women and activists from Uttar Pradesh told Human Rights Watch that they did not like going to government healthcare facilities because they are shut, doctors are not present, medicines are not available, or they are too far away.[25] Where a woman's own experiences discourage her from going to a healthcare facility, it is unlikely that information and education programs about facilities or schemes will sustain her motivation to seek care. More nuanced health interventions such as measures to improve the trust in the health system should be taken, for instance, by improving quality of care and creating easily accessible and effective grievance redressal mechanisms.

Reduction Strategies

There is broad global consensus on three critical maternal-mortality-reducing strategies-skilled attendance at birth, access to emergency obstetric care, and access to referral systems. While these three strategies are necessary, they are not sufficient to achieve a 75 percent reduction in maternal mortality.[26]

Available research suggests that access and ability to utilize emergency obstetric care will have maximum impact on maternal mortality. Basic emergency obstetric care includes the ability to conduct assisted vaginal deliveries, remove placenta and retained products, and manage pregnancy complications by intravenously introducing or injecting anticonvulsants, oxytocic drugs (drugs that expand the cervix or vagina to facilitate delivery), and antibiotics.[27] Comprehensive emergency obstetric care includes the ability to provide life-saving interventions including through surgery (cesarean sections) and blood transfusions.[28] Quality basic and emergency obstetric care are dependent on factors such as availability of adequate health personnel trained in midwifery skills, specialists such as anesthetists, gynecologists, and surgeons, adequate infrastructure such as blood banks, blood matching ability, sufficient supply of drugs, and good referral systems.     

Skilled birth attendance refers to the presence of health staff trained in midwifery at birth. A skilled birth attendant's ability to save a pregnant woman is limited unless she is supported by a robust health system that includes emergency obstetric care and referral support. Some experts argue that "the skill level of the attendant needed at the peripheral level [sub-district including village level]...depends upon the ready accessibility and acceptance of referral care."[29]

The most skilled attendant cannot save a woman experiencing life-threatening pregnancy-related complications unless she is able to reach the appropriate health facility in time. A strong referral system is not limited to ambulance services. It must at a minimum provide obstetric first aid in case of emergencies and have easily accessible and affordable around-the-clock health care and referral facilities that connect both private and public health facilities.[30]

For all three core interventions to successfully reduce and eliminate preventable maternal mortality and morbidity there has to be a functional public health system. Hence the global priority that is being given to maternal mortality reduction is increasingly hailed as an opportunity to improve public health systems.[31]

International Commitments and Progress on Maternal Mortality Reduction

International and national efforts to reduce maternal mortality span several decades. Concerted global efforts have been made in the last two decades including the 1987 Safe Motherhood Initiative and the 1994 International Convention on Population and Development, which reaffirmed governments' commitment to the issue.[32] And through the Millennium Declaration, 189 countries pledged to achieve eight development goals by 2015, including a 75 percent maternal mortality reduction compared to its 1990 levels.[33] In 2009, in a special session of the Human Rights Council, governments committed to adopting a human rights approach to preventable maternal mortality and morbidity.

But few governments are making adequate progress to achieve a 75 percent reduction in maternal mortality by 2015.[34]There has been less progress in meeting the maternal mortality reduction goal than in meeting any of the other seven MDGs.[35] Even progress in measuring maternal mortality is lacking: a recent international study of 68 countries states that "[t]rends in maternal mortality that would indicate progress towards MDG 5 [maternal mortality reduction] were not available."[36] The authors noted that maternal mortality was high or very high in 56 of the 68 countries. Further, high rates of HIV/AIDS, malaria, and tuberculosis have actually resulted in an increase in maternal mortality in several countries.[37]