Maternal mortality is defined by the WHO as the “death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes” (Who.int, 2004). Worldwide, approximately 830 women die every day from pregnancy or childbirth-related complications and the distribution is skewed, with 99% of these deaths occurring in developing countries (World Health Organization, 2016). Maternal death can be attributed to two different types of causes: direct and indirect. Direct causes of maternal mortality are those due to complications that can only arise due to a direct result of pregnancy, like severe bleeding (mostly after childbirth) or eclampsia (World Health Organization, 2016). Indirect causes are the deaths from medical conditions that are aggravated by pregnancy, for example Malaria or Cardiovascular disease (WHO et al., 2010). In this essay I will address the differing risks of maternal mortality between countries and then look specifically at policies implemented in Nepal, Malawi, Cambodia, Bangladesh and Rwanda and assess how effective the use of policies has been to address the inequalities underpinning maternal mortality.
The Global Distribution of maternal mortality:
Less than 1% of maternal deaths occur in high-income countries with the average maternal mortality ratio in 2015 of 12 per 100 000 compared to 239 per 100 000 in developing countries (World Health Organization, 2016). Figure 1 represents the maternal mortality ratio of countries in density circles, the larger the circle the higher the maternal mortality ratio. It is clear from this diagram the greatest burden is seen in Sub-Saharan african countries and South East Asia, followed by South and Central America and that high income countries such as Australia Canada and the UK have a much lower maternal mortality ratio.
What are some of the risk factors and how do they differ between countries?
Lack of maternal healthcare is the most significant risk factor contributing to maternal mortality (Thaddeus S., Maine D. 1994) as it postpones the provision of appropriate treatment, thus increasing the risk of maternal death. Most “maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known” (World Health Organization, 2016) and the WHO estimates that at least 88–98% of maternal deaths can be averted with timely access to healthcare (Apps.who.int, 1994). The three delays model identifies the phases of delay that affect reaching and receiving maternal care and it is a framework that addresses not only the availability, accessibility and quality of healthcare available but also the complex interlinking of socio-economic, cultural, geographical and religious driving factors behind seeking maternal healthcare:
delay in deciding to seek appropriate medical
delay in reaching an appropriate obstetric facility
delay in receiving adequate treatment
Delivery with a skilled birth attendant, antenatal care and emergency obstetric procedures are some of the major maternal healthcare interventions that can reduce the risk of maternal mortality. The availability and quality of care differs between countries causing differing risk of maternal death. For example, looking at Chad which has 1,200 per 100,000 live births, only 23 per cent of women were assisted by a qualified personnel while giving birth in 2010 (UNICEF, 2015). In contrast, Cuba which is also a developing country has a maternal mortality ratio of 73 and 99.9% (UNICEF, 2013) of women were assisted by qualified personnel while giving birth. Cuba has comprehensive provision of healthcare and high usage which results in a very low risk of maternal mortality due to healthcare issues.
The extent to which cultural and socio-economic factors drive the three delays model also varies between countries and results in differing risk. In Nepal for example, cultural norms can impede maternal healthcare seeking. In a study looking at the utilisation of skilled birth care in mid- and far-western Nepal, many women were ‘ashamed to deliver at the health facility’ and the practice of untouchability (isolating women during delivery and a few days after childbirth) prevented practising women from visiting a health facility and using a skilled birth attendant (Onta et al., 2014).
Having an unsafe abortion is also an important risk factor for maternal mortality accounting for 13% of global maternal deaths, with 68,000 women dying annually (Haddad B. et al., 2009). The number of unsafe abortions is very variable worldwide with the highest incidences of abortions that are unsafe occurring in Latin America, Africa, and South East Asia. The variety arises between countries due to many interlinking factors including strict abortion laws, low contraceptive use and social, religious, and political obstacles. Figure 2 shows the worldwide distribution of abortion laws, with countries in red banning all abortions or allowing abortions only on the grounds of physical health or preserving life. When comparing this to the incidence of unsafe abortions (figure 3) it is evident that there is a correlation between stricter laws and higher usage abortion rates.
However other factors also influence unsafe abortion and lead to increased variation of the risk factor. Nepal has legalised abortion however it still has a higher prevalence of unsafe abortion compared to the UK for example where abortion is also legal. In 2014, out of the 323,100 abortions, 63,200 women were treated for abortion complications (Puri M. et al. 2016). This can be attributed to quality and access to healthcare delivery but also obstacles such as social stigma, lack of awareness of the legal status of abortion and gender norms that hinder women’s decision-making autonomy (Thapa S et al., 2014). In contrast, the UK has a widely distributed, high quality and free abortion services with much higher female autonomy. In 2016 there was one death following an abortion according to England and Wales abortion statistics (Gov.uk, 2016).
Teenage pregnancy is another risk factor for maternal mortality and complications during pregnancy and childbirth are the second cause of death for 15-19 year-old girls globally (World Health Organization, 2014). Teenage pregnancy is linked to maternal mortality in a number of ways but mainly that it increases the likelihood of complications. Teenage pregnancy rates differ hugely between countries, largely due to cultural influence and contraception use prevalence. About 16 million girls aged 15 to 19 and 1 million girls under 15 give birth every year with the highest burden in sub saharan Africa (World Health Organization, 2014). Figure 4 illustrates the worldwide distribution of teenage pregnancy worldwide and shows particularly high prevalence in Sub-Saharan Africa, Latin america and countries in Asia.
Child marriage is strongly associated with early childbearing (Montgomery C., 2005) and as a result, countries where child marriage is more cultural acceptable and prevalent, the risk of maternal mortality by adolescent pregnancy is higher. Figure 5 shows the percentage of women aged 20–24 who were married or in union before age 18. It is clear that Africa, Asia and Latin America has the highest prevalence of child marriage and this correlates with the distribution of the adolescent birth rate distribution between countries (see figure 4).
Teenage pregnancy is also associated with increasing the risk of unsafe abortions, which in turn increases the risk of maternal mortality. Globally, women and adolescent girls under the age of 25 account for almost half of all abortion deaths (Montgomery C., 2005) and in Nigeria for example, more than 20,000 Nigerian women who die from unsafe abortions each year are adolescents (Raufu A. 2002).
HIV is another important risk factor linked to maternal mortality. A WHO analysis estimated that worldwide in 2008, 61 400 maternal deaths (18% of all maternal deaths) were attributable to HIV (Hogan M.C., et al. 2010) and other research indicates HIV-infected pregnant women have 10 times the risk of dying during pregnancy and the postpartum period compared with uninfected pregnant women (Moran N. et al., 2012). Therefore countries with higher prevalence of HIV disease are therefore at a higher risk of maternal mortality. For example, South Africa, has a very high HIV prevalence rate, with 18.92% of the population living with HIV/AIDS with lack of education, poverty, misguided beliefs about the disease and sexual violence contribution to these high rates (Cia.gov, 2016). As a result the risk of maternal mortality from HIV is very high with 70.4% of maternal deaths in South Africa associated with HIV infection in 2011 (Barron et al., 2012).
The effectiveness of policies to address inequalities underpinning maternal mortality
Removing user fees and providing financial incentives for maternal health care use are policies that can be implemented with the aim of reducing the financial and geographical inequity involved with seeking and accessing health services. They can provide an immediate reward to individuals for behaviour that culminates in health gains, and have been used to target a range of health-related behaviours.
In 2005, Nepal introduced a Safe Delivery Incentive Programme which provides cash payments (varied by ecological region) to women who deliver in facilities, and incentive payments for health workers who undertake home deliveries. The financial incentives aim to addresses the supply and demand side barriers to service uptake, and respond to the needs of different nepalese communities. Higher incentives are available for available for women in mountain and hill districts (Bhattarai A. et al., 2016) with the aim of reducing the financial and geographical inequalities associated with accessing healthcare. In 2009 the Nepalese government further strengthened their efforts to address the inequalities associated with maternal mortality by introducing a policy that removed user fees for delivery (the Aama policy) (Sato M. et al., 2015).
The maternal mortality rate has fallen from 444 per 100,000 live births in 2005 to 258 per 100,000 live births in 2015. This ten year period also had the highest annual rate of maternal mortality reduction at 5.4% per year since the monitoring of maternal mortality decline began in 1991 (Who.int, 2015).
Successful implementation of the safe delivery incentive policy improved the proportion of institutional deliveries (19% increase) and increased staff attendance at births (Witter et al., 2011). Figure 6 shows the distribution of place of delivery over time and there has been a drastic improvement with the proportion of deliveries conducted at home reducing from 80.9% in 2004-2006 to 59.4 during 2009–11 which coincides with the introduction of the policies. A report on the national free delivery policy looking at evidence of its effects found that overall quality of care improved particularly after the introduction of the Aama policy with staff being able to ‘fund drugs and supplies and to treat people quickly and equally, without worrying about their ability to pay’ (Witter et al., 2011).
However, although overall there was an increase in use of facilities for delivery and mortality rate decreased, the disparity between the richest and poorest quintiles remains large. Figure 7 shows the progression of the use of health facilities and separates the wealth groups into quintiles. It is evident that the introduction of the policies did not effect the poor quintiles nearly as much as the richer quintiles. The rich–poor gap shows that there still lies large inequity between the wealth groups for use of facilities and therefore maternal mortality.
Mali introduced a policy to improve equity in access for caesarean sections through the removal of user fees. Given the risk associated with lack of emergency interventions to maternal mortality, affordability of such producers is a major inequality underpinning maternal mortality. Although the policy did increase caesarean use enabling more obstetric emergencies to be treated, the policy was found to benefit the rich substantially more than the poor. Women in the richest two quintiles accounted for 58 percent of all caesareans, while women in the poorest two quintiles accounted for 27 percent of all caesareans (El-Khoury M. et al., 2012). This is because the financial barriers to accessing priority maternal health services was not the only barrier to obtaining care. The policy failed to address other underpinning inequalities amongst different wealth groups to ensure equal access. Women in poorer areas still had to contend with persistent geographical, transportation, and cultural barriers to seeking and accessing facility-based care which the policy did not address (El-Khoury M. et al., 2012).
Similar challenges were experience Ghana maternity fee exemptions where implemented, hindering the effectiveness of the policy. Although it had an overall positive impact, the uptake of skilled birth care over the policy periods for the poorest women was trivial when compared with their non-poor counterparts. A study examining the policy’s effect on the poor found that only 24% of the poorest had skilled birth care compared with 95% amongst their richest counterparts. The poorer areas often had a lack of ‘access to services’, ‘poorer quality care’, ‘cultural barriers’ and ‘lack of information about fee expeditions’ (Johnson et al., 2015).
However, financial policies aimed specifically at the poor alongside general financial incentives have shown to be effective. In Cambodia, the Ministry of Health initiated a voucher scheme in 2007 to complement an existing Health Equity Fund (HEF) scheme for improving access to safe delivery for poor women in three rural health districts. A study on the effectiveness of the programme found that the scheme was successful in enabling poor women to access institutional deliveries and reducing use inequalities. Facility deliveries increased sharply from 16.3% of the expected number of births in 2006 to 44.9% in 2008 (Ir et al., 2010). Many of the village health volunteers and traditional birth attendants interviewed claimed that there were almost no home deliveries any more in their villages as the traditional birth attendants referred all pregnant women to health centres for delivery (Ir et al., 2010). In another report published by the WHO, the probability of delivery in a public health-care facility as a result of the scheme was significant for poor women but not for non-poor women (Van de Poel et al., 2014).
Inequality of education also underpins maternal mortality, with evidence showing that lower levels of maternal education are associated with higher maternal mortality even amongst women able to access facilities providing maternal care (Karlsen et al., 2011). Increased education should increase the awareness amongst women on the risks of maternal mortality and the benefits of seeking maternal healthcare. Policies working more directly in and amongst communities have been shown to have a positive effect at reducing the inequalities associated with accessing healthcare.
For example, in Banladesh, the Safe Motherhood Promotion Project (SMPP) was conducted in the Narsingdi district and the intervention included community mobilisation through participatory approaches and strengthening of organisational and personnel capacities for delivering emergency obstetric care (EmOC). A controlled study indicated that this intervention led not only to more use of skilled birth attendants but also ‘a reduction of inequalities in access to skilled birth attendants’ (Kamiya Y. et al., 2013).
To support its ‘home birth’ to ‘facility–based childbirth’ policy, Rwanda has implemented a community health worker scheme which has decentralised the health sector improving the reach of the health system and bringing health services closer to hard-to-reach and marginalised communities. Since its implementation there has been increased awareness of maternal healthcare and increased demand for its services. Community health workers played a vital role in linking communities with health facilities and providing relevant support for health promotion, maternal health service delivery and HIV prevention (Maurice, 2016). Family planning education has contributed to the rise in contraceptive prevalence from 4 percent to 45 percent from 2000 to 2010 (Prb.org, 2012). However the policy is only effective when coupled with increased health service provision. With 40% of women living more than an hour away from a health facility, there are still geographical inequalities preventing equitable access to care (Prb.org, 2012). Restriction on resources and insufficient capacity of the national health system to provide the health workers with adequate skills for effective implementation have also meant that the enrolment of the programme is not equal across the country (Maurice, 2016).
In conclusion, maternal mortality differs widely between countries due a variety of interlinking risk factors such as education, religion and culture as well as the availability and quality of healthcare.
I believe policies can be effective for reducing the inequalities that underpin maternal mortality but only to a certain extent. They can help improve the structural determinants of health inequalities (education, occupation, income, socioeconomic status) and the basic socioeconomic development of the countries. However, there are many barriers to reducing inequality which requires more than governmental policy. Cultural and religious factors require a more deep rooted societal change which often lies beyond the realms of policy. Policies are also restricted by the resources of a country, whether that is lack of health workers or capital to provide high quality schools in all geographical areas. In the future, targeted approaches focused on marginalised groups I believe are the most important to reducing the underpinning inequalities of maternal morality.