Maternal Mortality and Sustainable Development
Maternal mortality is defined by the World Health Organization as the death of a woman while pregnant or within 42 days after pregnancy is terminated. This includes all deaths irrespective of the duration of the pregnancy and from any cause related to the pregnancy, childbirth, or conditions aggravated by pregnancy, including deaths associated with the management of pregnancy. This excludes the death of pregnant women who die due to unrelated causes such as accidental or incidental events. Sustainable development refers to the phenomena of development interventions that are able to be maintained over long-term periods of time without significant risk of action ceasing, thus providing resultant improvements in developmental outcomes.
In 2015, world leaders met at a United Nations summit and decided on a set of 17 Sustainable Development Goals, including goal number 3: good health and well-being. Within each goal, additional targets were also defined, including a goal to, “by 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births” (The United Nations Sustainable Development Solutions Network 2012). Maternal mortality remains a large problem that heavily affects the health sectors of developing nations, with the World Health Organization estimating that 830 women die every day from preventable causes related to pregnancy and childbirth. Furthermore, 99% of all maternal deaths are estimated to occur in developing countries (Peterson et al. 2012). Maternal mortality is a severe and continued social injustice: it discriminates against women and is most profound in populations that are poor or face socioeconomic inequality. The nature of maternal mortality requires intervention that is founded in sustainability, in order for long-term benefits to be observed (Okonofua 2006). This article will build on past research and findings to examine the causes and preventative strategies most commonly associated with maternal mortality. It will then seek to unite such evidence and offer sustainable solutions and improvements to past initiatives working to reduce maternal mortality ratios.
Defining Maternal Mortality
It is essential to understand two dimensions to maternal mortality – those deaths related to induced abortion and those not. Both share similar causes and can be prevented using related methods. However, it is often useful to consider them individually when first beginning to understand maternal mortality. Maternal mortality does not affect all women all over the world equally. Women living in developing countries and those without access to quality care are the most at risk. Those who live in rural locations are at increased risk of maternal mortality, related to their inability to access emergency care in time, as well as the reduced likelihood of them attending recommended prenatal checks and having access to skilled birthing attendants (Lundborg 1988). Young adolescents are also unequally affected by maternal mortality, which may be linked to impaired abilities to access quality medical care, potentially related to the stigma sometimes associated with young age and pregnancy (Nove et al. 2014). Furthermore, those women with identifiable medical risks such as HIV or other chronic illnesses are often at higher risk of maternal mortality. Women who have had complications with previous pregnancies, such as stillbirths or miscarriages, also face higher risk (Pillai 1993).
Importantly, culture often plays a significant role in determining what healthcare pregnant women can access. In some communities, unmarried and pregnant women may be pressured into undergoing unsafe abortions, during or after which complications may result, causing the death of the mother. Some of these women may also be denied access to public health services that are required for safe births (Mmusi-Phetoe 2016). Others may not have access to family planning services that would allow safe abortions without discrimination (Akter et al. 2018).
The prevalence of maternal mortality is difficult to measure. Existing ratios of maternal mortality are highly likely to be incomplete or inaccurate due to lack of accurate data collecting infrastructure in some states. This is most likely to be relevant to those countries where maternal mortality poses one of the most significant public health problems (Yamin and Maine 1999). Furthermore, many mothers also die outside of healthcare facilities where data collection is usually most reliable and where their death can be recorded (Mgawadere et al. 2017). Even if some women are accounted for as dead, it may not be listed that they were pregnant, resulting in data that may be further compromised. It is likely that currently provided maternal mortality ratios underestimate the true extent of these public health burdens, particularly in those states most greatly affected (Sharma et al. 2017). Despite this, existing data estimates that the maternal mortality rate of North America is approximately 11 deaths per 100,000 live births and that the maternal mortality rate of Africa is about 870 deaths per 100,000 live births (WHO 2016). With the mortality rate of Africa almost 80 times higher than that of North America, it can be seen that maternal mortality is a strong indicator of the resource disparity between developed and developing countries.
Causes of Maternal Mortality
Understanding the underlying causes of maternal mortality can provide great insight into what future effective preventative interventions may involve. This section will discuss six key causes and precipitating factors of the high rates of maternal mortality that exist today. These involve specific medical factors which can cause maternal death, which may or may not be exacerbated by other influences impacting the mother. Such other factors may include the high prevalence of gender discrimination (particularly that related to women’s health services, poverty, and lack of education). Unsafe abortions are also a key contributor to these high rates that will be discussed, as well as the inadequacy of health infrastructure.
It is useful to first gain an understanding of the medical challenges associated with maternal mortality. The most common three medical causes of maternal mortality are hemorrhage, sepsis, and hypertensive disorders. Hemorrhage is bleeding caused by rupture of blood vessels that can cause significant blood loss and later potentially the death of the mother. Hemorrhage may be initiated by trauma to the mother’s uterus during labor or other causes such as during or after unsafe abortions if methods are used which may cause injury to the woman’s uterus or other internal tissue and thus have the potential for rupturing blood vessels. Hemorrhage is a regular cause of maternal mortality due to the rapidity at which it may result in death if left untreated. Pregnant women who hemorrhage may die in less than an hour if they do not have access to skilled medical staff who are trained for such situations, as well as resources such as blood transfusions or operating rooms when needed.
Sepsis is an infectious state caused by the introduction of pathogenic bacteria or other microorganisms or foreign material that can cause pathology. For example, if childbirth takes place in an unsanitary location, or the hands of potentially unskilled birth attendants are unclean and come into contact with the mother, infections can be caused with sepsis as the result (Acosta et al. 2016). The manifestations of sepsis may occur some days after childbirth or abortion, and the risks associated with fatality are often potentiated when families are uneducated about the symptoms that may be linked to severe disease and the nature of sepsis as an often fatal illness (Hirshberg and Srinivas 2017).
Hypertensive disorders are disorders of high blood pressure. These may induce maternal mortality due to acute pathologies such as stroke or heart attack. Hypertensive disorders can cause death rapidly if they are not remediated and attended to by trained medical staff with the necessary resources (Lo et al. 2013).
It is also important to acknowledge the role of secondary diseases in contributing to maternal mortality. For example, women who are HIV/AIDS positive are at significantly higher risk of maternal mortality. This is mainly related to increased risk of severe bleeding, as well as increased risk of becoming septic due to reduced immune system function (Tessema et al. 2017). Women who have had medically identified complications in previous pregnancies are also more likely to develop fatal complications. This includes women with a past history of miscarriage, stillbirth, or complicated past pregnancies (Tessema et al. 2017).
It is essential to carefully consider the significant role of gender discrimination in maternal mortality. Factors such as early marriage and the often low status of women in society and their dependence on others can be undermining and contribute significantly to the inability of individual women to accessing necessary care. The role of different cultural traditions in potentiating the weakened role of women and the absence of their autonomy can also be significant factors in gender biases disfavoring women from attaining quality healthcare. When women face abuse related to pregnancy as many have reported, or when their autonomy is undermined, it can be difficult for them to make independent choices about their health both during and after maternity. In the past, many developing nations have failed to prioritize maternal mortality rates often related to decreased perceived urgency over women’s health problems, as compared to other challenges that may more significantly affect men (Morgan et al. 2017). This is reinforced by the fact that there is no other single cause of mortality in men of fertile age that is as high in magnitude as maternal mortality (Parnell 1989).
Poverty is a significant limitation on women being able to access quality medical and obstetric care related to their pregnancy. This is particularly linked to those who live in rural locations, without feasible transport options that are required to access both prenatal and emergency obstetric care (Zolala et al. 2012). Before giving birth, it is recommended for women to seek scans and checkups associated with their pregnancy in order to ensure that the fetus is developing well and that any dangers associated with the pregnancy may be identified early in order to assure relevant plans are made for safe delivery and preventing the risk of maternal and child death. Women who live rurally are more likely not to receive these checks and thus have higher chances of proceeding with potentially dangerous births or doing so without the appropriate care plan and resources in place. For many rural communities, lack of transport is a significant problem related to unsafe births, as those who are unable to access care in time are often forced to deliver in hazardous or unsanitary conditions, in the absence of a skilled birth attendant who may be able to prevent maternal death or other complications (Tlou et al. 2017). Giving birth outside of a hospital also carries other resource-associated risks, including the inability to access resources such as blood transfusions, cesarean sections, and clean birthing equipment which may be able to prevent maternal death (Tessema et al. 2017).
Women who are uneducated face additionally increased risks of maternal mortality when making choices regarding their pregnancy. Some women may not be aware of recommended services or resources that are available to keep themselves and their baby healthy. Others may choose unsafe methods of abortion if they are not educated surrounding the potential associated risks. Both scenarios may result in maternal mortality due to compromised safety. Without adequate levels of education, particularly surrounding pregnancy and childbirth, women can feel disempowered to make decisions about their healthcare and often fall victim to the choices that others make for them, who may not have their best interests in mind (Bauserman et al. 2015).
For women who wish to undergo an abortion, restrictive abortive legislation can often be a significant factor in them electing to undergo unsafe abortions, which may, in turn, result in maternal death. Poor quality of family planning services and severe stigma may also be associated with these choices. Many states do not allow legal abortions or provide access to family planning, and in those states that do offer these services, they may be costly and unattainable for some women living in poverty. Biased information is often circulated which can pressure women into making risky decisions regarding their pregnancy. Her own culture and the culture of those around her may also have a significant impact on the choices made by the woman regarding her own pregnancy and care (Morgan et al. 2017).
Inadequate health infrastructure including the limited capacities of hospitals in many developing countries and the limited availability of skilled healthcare workers also contribute to maternal mortality. Many of the healthcare workers in hospitals of developing countries are unskilled, and healthcare resources within hospitals can still be extremely scarce. The resultant care provided is of low quality and is often unprofessional. For example, high rates of abuse are reported by many women in Malawi who utilize public health services for childbirth (de Groot et al. 2015).
There are many angles from which it is useful to consider current and potential future preventative initiatives against maternal mortality. This section will discuss the past mechanisms employed by providing additional skilled obstetricians and training, as well as more clearly identifying those individuals at higher risk of maternal mortality. The roles of improving health infrastructure will also be considered, as well as encouraging more women to give birth in health facilities and improving emergency obstetric services. Improved access and quality of family planning services will further be discussed as a key intervention, as well as the impact that improving the overall health of mothers can have.
The most widely reported effective solution resulting in improvement in mortality rates so far in time has been advancements in obstetric medical care and the provision of more skilled medical obstetric workers. Previous historical declines in maternal mortality ratios coincided with these improved standards in medical obstetrics and interestingly remained resistant to changes in hygiene and sanitation standards. This indicates the significant role of skilled healthcare staff in enacting positive changes in maternal mortality ratios (Rigó et al. 2014). These workers can provide substantial benefit to pregnant women by providing safe, quality, professional care. When women have access to quality care and quality advice about their pregnancy, they can make informed decisions, and risks associated with their pregnancies can be minimized by the knowledge of these workers, who have experience and understanding of the potential complications related to pregnancy and how such risks may be minimized. For those women who elect to undergo abortions, skilled healthcare workers are again significant in ensuring patient safety throughout the procedure and afterward (Mukaba et al. 2015).
It is furthermore essential to identify women who may be at high risk of maternal mortality. Certain factors can render some women more likely than others to have pregnancies with higher risks of complications. For example, women who have had previous stillbirths are at higher risk of birth obstruction (which often requires cesarean section), and those who have had more than four children are often at higher risk of hemorrhage due to the loosening of uterine wall smooth muscles. If these women can be identified early, it can be possible to ensure that they are provided with the resources and support they need to ensure that their risks are reduced. It is often vital for plans to be made regarding complicated pregnancy and childbirth, so acknowledging the higher risk status of these women may give health support teams more time and greater ability to prepare for potential complications and thus reduce the likelihood of maternal death (Bauserman et al. 2015).
Improving existing health and reproductive health infrastructure is further essential in ensuring the best outcomes for pregnant women. In developing countries, even when women are able to reach hospitals, the care provided is often minimal. This may be due to lack of material resources or disparity of employees that may help in ensuring the provision of quality care. This is not limited to hospitals and clinics but also extends to family planning initiatives which are often absent or scarce in many developing nations. Family planning is crucial to women’s rights and equality – it must not be ignored when considering the development of all infrastructure related to women’s general and reproductive health. These measures can coincide with increased public sex education, particularly surrounding the use of contraceptives and how safe abortions can be obtained (Bauserman et al. 2015). All such information should be delivered without bias and with discouragement toward negative stigma often associated with such topics.
Governments can also make significant contributions to maternal mortality rates by encouraging women and their families to give birth in regulated health facilities. These facilities are generally safer and usually have more quality skilled birth attendants. They are also more likely to have resources that may be necessary for complicated pregnancies, such as materials for blood transfusions or cesarean sections when needed. States should also prioritize targeting the most vulnerable and at-risk women, to ensure that they have an understanding of the resources they may need during pregnancy and how they can make the best decisions that keep themselves safe. Improving screening procedures for the identification of these potentially at-risk women can be equally important in making sure that they can be efficiently targeted (Deneux-Tharaux and Saucedo 2017). Education is crucial in all of these measures and should be provided freely and without bias. Encouraging the continued professional development of medical and birthing staff is furthermore important, as those who are well trained and competent in ensuring safe births and utilizing necessary services when complications arise can make a significant impact in reducing mortality rates.
Ensuring the implementation of policies that give access to quality emergency obstetric care is vital in providing better outcomes of particularly those mothers living in rural locations. Policymakers must give particular consideration to the need for efficient transport solutions and plans for pregnant women accessing health facilities both during childbirth and pre- and postnatally to ensure that the risks of potentially fatal complications can be minimized (Midhet et al. 1998).
Family planning service development is crucial in ensuring the reduced incidence of maternal mortality, particularly that associated with unsafe abortions. In many developing nations which face the most significant problems related to maternal mortality, family planning services may be nonexistent or incomplete. The presence of safe and accessible services can lead to reductions in maternal mortality rates associated with unsafe abortions. When secure services are not provided, women may elect to use or be pressured into turning to risky and dangerous alternatives, potentially causing complications that result in death (Ahmed et al. 2012). States must remain vigilant in ensuring that such unsafe services can be shut down and controlled. Comprehensive sex education must also be provided to women to ensure increased understanding of pregnancy, childbirth, potentially related pregnancy complications, and dangers of unsafe abortion or unsafe childbirth practices.
Improving the overall health and well-being of mothers during their pregnancy can play a significant role in reducing the risk of mortality (Curamericas 2013). When mothers are healthy and are in states of good well-being, the risks associated with maternal mortality can be reduced. However, when mothers are malnourished or unhealthy, the chances of complications that can lead to maternal mortality increase (Binns et al. 2017). Thus, policymakers need to consider the health and well-being of all mothers throughout their pregnancy, rather than just the health of their child alone. Mothers who are unhealthy must be supported with interventions that seek to defend their well-being, and education can play a crucial role in ensuring that these mothers have an understanding of how they may protect themselves in attaining the best levels of health.
The Universal Declaration of Human Rights adopted by the UN General Assembly in 1948 states that “All human beings are born free and equal in dignity and rights” (The United Nations 1948). Stakeholders should be aware of this in considering the significant inequality that exists in affecting women as the sole bearers of maternal mortality rates. Because maternal mortality primarily directly affects only women, states must prioritize measures to reduce such rates as they are significant indicators of gender-health inequality.
The International Covenant on Economic, Social and Cultural Rights in 1966 states that every person has “the right to the highest attainable standard of physical and mental health.” This applies to all women who wish to access care associated with childbirth and pregnancy or abortion. High maternal mortality rates of developing countries are significant indicators of gaps in the provision of health resources; it is thus necessary that all women, regardless of race, religion, socioeconomic status, marital status, or other factors, are allowed the opportunity to access high-quality, professional standards of care. Furthermore, these women also have the right to access comprehensive, safe, and unbiased information related to their pregnancy (Sexual and Reproductive Justice Collaboration 2018). These rights are very basic, and policymakers must remember the emphasis on all women having equal access to such resources. This includes women who live rurally, those who are poor, and those who are unmarried. Fair policy cannot be developed if it prioritizes a particular group of women or neglects others.
Strengthening all of the rights of women in nations which are most affected by maternal mortality is vital in encouraging sustainable solutions to high maternal mortality rates. When women are safe, are respected, have equal access to education and healthcare (even that not directly related to pregnancy or childbirth), and are empowered to live independent lives of value, they also have greater ability to take responsibility for their health and well-being and seek services that are of higher quality. When women have their rights upheld, they are also more likely to ask for help when needed and are in better positions to make good decisions about their care and well-being (Nair et al. 2012). Furthermore, when women have more significant roles in society and are offered higher levels of opportunity and respect by their peers, they can pursue healthcare services with less of a risk for unfair treatment due to their gender, as well as decreased risk of abuse or unprofessional or biased service. Educated women have greater ability to discern safe practices from unsafe and make better choices about their care. Those women who understand their rights are also more likely to exercise them and avoid situations where they may be pressured into unsafe childbirth or abortion practices. And in nations where justice systems act fairly in regard to women’s rights breaches, practicing health professionals can be held accountable for their actions, which may help reduce some related burdens such as abuse or incompetent care that both contribute to high maternal mortality rates. Furthermore, countries in which women have the most significant protection over their rights can support reduced maternal mortality rates by the assurance that they can access family planning clinics that provide safe abortions, such as every person’s right to safe reproductive healthcare requires (Mmusi-Phetoe 2016).
Maternal Mortality and Sustainability
It is critical to consider the role maternal mortality has in promoting the long-term sustainability and achievement of all 17 of the Sustainable Development Goals. This section will focus on these greater links of maternal mortality to sustainable development, as well as what interventions can be put in place to ensure that improvements in maternal mortality rates are made sustainably for long-term benefit. Focus is placed on pairing interventions and finding areas of potential overlap in order to reduce costs and strengthen support. Patience in investment and support for short-term establishment expenditure is further necessary.
Maternal mortality has much greater significant impact aside from that directly affecting the mothers themselves and their families. In addition to the immediate consequence of loss of life, maternal mortality stimulates cycles of poverty, with the death of mothers often leading to other children within the family having to leave education in order to take care of siblings. Further aggravating this cycle, maternal mortality often results in reduced family income due to the loss of one income stream, which may lead to further potentiation of poverty. When children of mothers who die during maternity grow up in poverty, or unable to access education, they are more likely to have reduced socioeconomic outcomes during their lives. Again, this unfairly affects girls who are more likely to drop out of school, become malnourished, or die. Thus, greater implications of maternal mortality result in lower outcomes for families across generations, as well as negative implications for the development of affected states. As the earning potential of these women is lost, as well as the resultant effects of children being at more risk of dropping out of school and attaining poor social and medical outcomes, the capacity for states to develop their economies may be reduced. This is also due to more people potentially relying on public healthcare resources due to secondary health implications, which may, in turn, increase the total health cost burden on such nations. When maternal mortality rates are reduced, all of society benefits. Women can enjoy safer health and well-being, with greater autonomy and freedom in access to care. Families benefit over generations as more women can contribute to supporting children, enabling them to remain in school and benefiting from improved educational outcomes. Women are also empowered to add to family income streams (Tessema et al. 2017).
Sustainability becomes an essential concept in maternal mortality when stakeholders can identify these potential cycles of poverty and the poorer economic outcomes for both families and states, as well as understand the necessity of developing solutions that can be implemented with significantly positive impact. It is vital that the long-term sustainability of resolutions related to maternal mortality can be ensured if nations wish to enjoy lasting benefits associated with reduced mortality ratios. It is firstly essential to consider how the preventative measures developed in order to reduce the risk of maternal mortality over time can be paired with initiatives that are being put in place to ratify other targets within the Sustainable Development Goals. This is particularly true for those that remain under Sustainable Development Goal number 3. For example, in considering the critical role of health education of families in improving knowledge surrounding healthy pregnancy, childbirth, and family planning, information on these topics can be integrated into educational syllabi of nutrition and nutritional deficiencies, for example, in recognizing signs of vitamin A deficiency and how it may be corrected. In doing so, costs may be reduced, and such services can be more efficient at targeting those most in need over time (Kruk et al. 2014).
Another example may be combining maternal vitamin A supplementation (which can prevent some severe diseases and pathologies due to correcting deficiency) with prenatal screening to identify any problems in the child’s fetal development. Both of these are crucial steps in helping to ensure positive progress toward the targets outlined by Sustainable Development Goal 3. If more women can access both screening measures and supplementation or nutritional support at the same time, benefits may result including higher rates of follow-up and greater population coverage, particularly among those women who live in rural locations or may be unmotivated by the prospect of traveling to receive one single supportive measure alone (Binns et al. 2017). These measures may further decrease associated costs, for example, those that are associated with identifying these target women, those costs required to publicize the availability of such services, and those costs that may relate to the provision of skilled healthcare workers as well as facilities in which these services can take place.
Identifying such areas of overlap can lead to broader benefits over different targets and more sustainable implementation over time. This is mainly related to instances in which operational costs may be reduced, for example, the cost of combined health education programs, as compared to delivering separate syllabi, or the cost of providing separate vitamin A supplementation programs and prenatal health checkups, as compared to combined visits. Other benefits of these approaches can also include the reduced transport costs associated for those rural families who are required to travel to access healthcare facilities, as well as greater motivation for these families to travel to these facilities (in order to receive two or more services, rather than one alone) (Melkert et al. 2015).
Interventions that target the reduction of other diseases such as HIV and tuberculosis can also have significant positive benefits on maternal mortality rates. This is related to the pathological effects of these diseases in causing significantly higher risks of maternal mortality. Importantly, those nations that generally exhibit higher rates of diseases associated with maternal mortality are often those states that also have the highest rates of maternal mortality, so the contribution of these diseases to maternal mortality should not be overlooked. Any reductions in the prevalence of such diseases will also support reductions in maternal mortality rates (GBD 2015 Maternal Mortality Collaborators 2016).
Initial reductions in maternal mortality, including short-term costs of acquiring facilities, training healthcare professionals, and obtaining resources with high up-front costs such as medical equipment, may be met by extended provision of aid to those states most in need. However, for there to be sustainable reductions in maternal mortality, states are encouraged to adopt such policies and framework into their healthcare budgets. Countries that can ratify their commitment to reducing maternal mortality rates by developing policy specifically for such purposes are likely to have more significant long-term, sustainable success in reducing maternal mortality rates. Furthermore, acknowledgment of states with direct action and contribution to reducing maternal mortality rates can have substantial benefits in encouraging community leaders and other organizations to focus on and prioritize such developmental areas (Nair et al. 2012).
Conclusions and Future Directions
Maternal mortality is a significant indicator of a nation’s level of healthcare development and is often described as one of the most important markers of a nation’s progress. Aiming to reduce these rates should thus be essential targets of every state, recognizing, in particular, the unjust gender inequalities that they exemplify. Reducing maternal mortality rates has a significant impact not only on the women who would otherwise be affected but also their children, their families, and the long-term economic and social development of their communities and their nations. Ending preventable maternal mortality has powerful, positive implications for all of society over time. All women have the right to access safe and quality healthcare, including all those services related to their pregnancy, during, before, and after birth. States must prioritize the provision of skilled healthcare professionals that are trained in obstetrics and emergency obstetric care, as historical data has shown that this has been the single most substantial factor in reducing maternal mortality rates. Public education is also crucial and should not be forgotten. Reducing maternal mortality is a challenge that requires long-term and sustained effort (CARE 2009). For sustainable solutions to be reached, it is worthwhile to consider the overlap of other health interventions and the potential for reducing costs while simultaneously increasing efficacy and outreach.
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