Why maternal mortality in the world remains tragedy in low-income countries and shame for high-income ones: will sustainable development goals (SDG) help?

Introduction

There is no sadder event in obstetric practice than the death of mother. Although some unsatisfactory progress has been achieved in decreasing maternal deaths in the last decades, the statement from the end of 1990s of Dr. Hiroshi Nakajima, the fourth Director General of the World Health Organization (WHO) is still actual: “Hundreds of pregnant women, alive at sunset last night never saw the sunrise this morning. Some of them died in labor, some died of hemorrhage in a hospital lacking blood, some died in the painful convulsions of eclampsia, and some died on the table of an unskilled abortionist trying to terminate an unwanted pregnancy” [1]. Besides to health negligence, women have been neglected in many other fields. One of examples is the right to vote (suffrage) as one of the basic human rights. If we look at the data when women were given the right to vote in certain countries, it will be quite a surprise due to the inequality that this right has caused in different countries [2]. For example, women in Switzerland gained the right to vote in federal elections after a referendum in February 1971, while in Saudi Arabia it happened in 2015 [2]. The right to health is another fundamental human right. If we look at a human right to health from the perspective of the shocking data on woman’s lifetime risk of maternal death which is recently in high-income countries 1 in 5,400 and in low-income countries 1 in 45 (defined as the probability that a 15-year-old woman eventually dies during lifetime due to pregnancy-related causes), we will be unpleasantly surprised [3]. This, more than 100 times difference between high- and low-income countries in the probability of dying due to the pregnancy-related causes is only one but drastic example of inequalities affecting women. Although both examples may seem unrelated, it may be the case that lower political rights are causing lower human and reproductive health rights [4, 5].

The aim of the paper is to analyze maternal mortality (MM) globally and how was it influenced by Millennium Development Goals (MDGs) and Sustainable Development Goals (SDGs) and what can and should be done do decrease it.

Maternal mortality ratio (MMR): definition and causes

The International Classification of Diseases (ICD-10) defines maternal death as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes [6, 7].

As shown in Table 1, maternal deaths are subdivided into two groups [6, 7]:

1. direct obstetric deaths are those resulting 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.

2. indirect obstetric deaths are those resulting from previous existing disease or disease that developed during pregnancy, and which was not due to direct obstetric causes, but which was aggravated by physiologic effects of pregnancy.

A late maternal death is the death of a woman from direct or indirect causes more than 42 days but less than one year after termination of pregnancy [6, 7]. Subsequent guidance on the classification of causes includes nine groups of underlying causes [7]. According to the WHO there are nine possible causes of maternal deaths given in Table 1 [6, 7].

Obviously, MM and morbidity are a public health issue, with little detailed knowledge available on their true levels and causes especially in low-resource or underdeveloped countries [8]. The data on MM and morbidity should rely on large population-based studies which are non-existent and the reason for estimates of MMR based mostly on the mathematical models [8]. Vital registration systems of maternal and infant mortality and morbidity are not established in low-resource countries, making maternal and infant health surveillance system unaccountable [9, 10]. This was the reason for United Nation’s Secretary General Ban Ki-Moon to launch the global strategy to accelerate progress for women’s, children’s and adolescent’s health with the accountability as the central part of the document [11]. This fact of low accountability of the data on maternal and infant health indicators is very important to mention at least for two reasons: the first is lack of awareness in low-income countries (LIC) on the importance of registration and follow-up of the data on maternal and infant deaths, and the second is lack of assistance of high-income countries (HIC) to help LIC to establish the national registration system of maternal and infant health indicators [11, 12].

Progress of declining maternal mortality in the world

For many decades World Health Organization (WHO) is trying to find the ways how to overcome inequality in MM between high- and low-income countries. As pointed out before, by the definition of the WHO, MMR is the estimated number of women, between the age of 15–49 years, who die from pregnancy-related causes while pregnant or within 42 days of termination of pregnancy, per 100,000 live births [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22]. As shown in Figure 1, estimated MMR declined from 430 per 100,000 live births in 1990 to 211 in 2017 which is 1.82% per year in 27 years [13], [14], [15]. Estimated absolute numbers of maternal deaths were 585,000 in 1990, 514,500 in 1995 coming to less than 300,000 nowadays, which is a substantial improvement [13]. An estimated global total of 13.6 million women have died in the 25 years between 1990 and 2015 due to maternal causes [23]. The global MMR has fallen by 44% (uncertainty interval UI 33.1–47.5%), from the 1990 level of 385 (UI 359 to 427) to the 2015 level of 216 (UI 207 to 249) [23]. This translates to a decrease of over 43% in the estimated annual number of maternal deaths, from 532,000 (UI 496,000 to 590,000) in 1990 to 303,000 (UI 291,000 to 349,000) in 2015 [23]. Worldwide, MMR declined by an average of 3.0% (UI 2.1–3.4%) per year between 2005 and 2015, more than doubling the estimated average annual decline of 1.2% (UI 0.5–2.0%) between 1990 and 2000 [23].

Figure 1:

Estimated world maternal mortality rate (MMR) from the year 1990 to the year 2017 [according to 13, 14, 23].

Regardless of substantial reduction in the last 30 years, MM remains neglected tragedy especially in low-income countries, which is the shame for high-income countries. That was the reason to launch MDGs with the aim to reduce by three quarters MMR between 2000 and 2015 [24]. However, after the analysis of MMR at the end of 2015, it decreased less than half, which was quite a disappointment [24]. This was the reason that during the United Nations General Assembly 2015, in New York, UN Secretary-General Ban Ki-moon launched the Global Strategy for Women’s, Children’s and Adolescents’ Health, 2016–2030, in which SDGs were defined [18]. The Strategy seeks to end all preventable causes of maternal deaths.

Regardless of the fact that SDGs have been launched, in 2017 the world has been faced with approximately 810 women dying from preventable causes related to pregnancy and childbirth every day, with 94% of these deaths occurring in low and lower middle-income countries [13]. Young adolescents aged 10–14 have been faced with higher risk of complications and death as a result of pregnancy than women of other age categories [5]. Accessibility to skilled medical care during pregnancy and especially during childbirth can save lives of many women. Still women are dying due to three delays: delay in decision to seek care, delay in reaching and delay in receiving care [12, 17], [18], [19], [20], [21]. Past noble and successful president of the International Federation of Gynecology and Obstetrics (FIGO) and founder of the Safe Motherhood Initiative professor Mahmoud Fathalla almost 20 years ago stated that “Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving” [19]. At that time had a wish for the world to “shed the shame, disgrace and the scandal of leaving mothers to suffer and die when they are fulfilling the noble task for survival of our species” [25].

Maternal mortality ratio (MMR) in the period from 1990 to 2015 according to the WHO estimates and Millennium Development Goals (MDG)

The WHO, in collaboration with the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNPF), the World Bank Group (WB), and the United Nations Population Division (UNPD), published global estimates of MM [8]. Because of high levels of MM at the beginning of 1990s which was estimated on the yearly basis on 532,000 of maternal deaths with the MMR of 385 maternal deaths per 100,000 livebirths, in September 2000, 189 world leaders signed a declaration on eight MDGs to decrease the discrepancy of maternal and infant health indicators between developed and developing countries [24]. Among eight MDGs, goal 5a called for the reduction of MM by 75% between 1990 and 2015 together with the MDG 5b which claimed for universal access to contraception [24]. Total number of maternal deaths decreased for 43% from 1990 to 2015 from 532,000 to 303,000 maternal deaths (range of uncertainty between 291,000 and 349,000), with decline of MMR from 385 to 216 (range of uncertainty between 207 and 249) of maternal deaths per 100,000 livebirths, which is decline of 44% or 2.3% per 1 year [24].

After the analysis of the countries in terms of meeting the targeted reduction of MM, there are four groups of countries [24]:

1. Those which achieved the targeted reduction of at least 75%,

2. those which accessed 50% of the reduction,

3. those which made insufficient progress, and

4. those which made no progress at all.

Out of 183 countries only nine countries achieved target of 75% of reduction of MM (Bhutan, Cambodia, Cabo Verde, the Islamic Republic of Iran, Timor-Leste, Lao People’s Democratic Republic, Rwanda, and Mongolia), 39 countries were characterized as having made a 50% reduction in MM; 21 countries have made insufficient progress; and 26 countries made no progress [13].

When analyzing the world MDG regions, the reduction rate of MM in percentages is shown for the whole period from 1990 to 2015 in Figure 2 according to [13].

Figure 2:

Reduction rate of maternal mortality in Millennium development goal (MDG) regions of the world in the period from 1990 to 2015 according to [13].

The MMR in different MDG regions is shown in Figure 3. It is evident that there is a huge discrepancy of the MMR between the regions, which can be expressed as the adult lifetime risk of MM defined as the probability that 15-year-old girl will die eventually from maternal cause [13]. In Sub-Saharan Africa the risk is 1 in 36, in Oceania 1 in 150, in Southern Asia 1 in 210, in developed regions 1 in 4,900 with the global number 1 in 180 [13].

Figure 3:

The maternal mortality ratio (MMR) in different MDG regions in 2015 according to [13].

Ten countries with the highest absolute numbers of maternal deaths in the year 2015 are shown in Figure 4. The countries belong to Africa and Asia, and they account for 59% of all maternal deaths in 2015. Low- and middle-income countries (LMICs, as defined by the World Bank) account for 99% (300,000) of global maternal deaths [13].

Figure 4:

Absolute number of maternal deaths in 10 leading countries of the world in 2015 according to [13].

According to some data, maternal direct causes account for 73.0% of maternal deaths, while indirect causes account for 27.5% of maternal deaths [7]. Among the direct causes hemorrhage account for 27.1% (95% confidence interval 19.9–36.2) (72.6% as postpartum hemorrhage), hypertension 14.0% (95% confidence interval 11.1–17.4), sepsis, 10.7% (95% confidence interval 5.9–18.6), abortive outcomes 7.9% (95% confidence interval 4.7–13.2), and embolism and other direct causes, 12.8% [7].

Indirect causes of maternal deaths particularly if combined, are the most common cause of maternal death, accounting for more than 70% of causes of maternal deaths especially from preexisting medical conditions like HIV/AIDS or COVID-19 pandemic [7], [8], [9].

Obviously MDGs did not reach the targeted aim of 75% of decline of MM in most of 183 participating countries. That was the reason to introduce the SDG in 2015.

Maternal mortality ratio (MMR) and Sustainable development goals (SDG)

As we have learned from MDGs, ending preventable maternal mortality (EPMM) remained an unfinished agenda [10]. Despite some progress achieved in the period from 2000 to 2015, high MM remains one of the world’s most critical challenges, since 800 women still die each day from largely preventable causes before, during, and after the time of giving birth [10]. Through concerted efforts in low-, middle- and high-income countries wide disparities in current MM could be reduced with the reduction of the highest levels of maternal deaths worldwide, which would be a great achievement reflecting the commitment to a human rights framework for health [10].

In September 2015, the General Assembly adopted the 2030 Agenda for Sustainable Development that includes 17 SDGs (Table 2) [10, 11]. Building on the principle of “leaving no one behind”, the new Agenda emphasizes a holistic approach to achieving sustainable development for all in many fields of life on Earth [10]. Compared to MDGs, SDGs had much wider perspective on improving quality of life with the intention to decrease inequity between the LIC, MIC and HIC.

Under the Theme 2 Personal health and well-being there are Global Goal 2 – No hunger; Global Goal 3 – Good health; and Global Goal 6 – Fresh water and sanitation [26]. Global Goal 3 has the aim to reduce MM by the year 2030 from global MMR of 120 to 70 per 100,000 livebirths and to end preventable deaths of mothers, newborns and under-five children [26]. Recently published report on SDGs analyzed how SDGs were implemented in the period of five years after the introduction [27]. Compared to MDGs, the SDGs regions are different, and comparison is not possible, it can be concluded that in many regions the target of MMR was not achieved in four out of six regions and percentage of births attended by skilled birth personnel is not satisfactory in two out of six regions as presented in Figure 5. If the same data were plotted on the high-, lower-middle-, and low-middle income countries, and Small Island Developing States and Sub-Saharan Africa (Figure 6), than the discrepancies are still significant, and it seems that they are not decreasing.

Figure 5:

Maternal mortality, life expectancy and births attended by skilled health personnel in East and South Asia, Eastern Europe and South Asia, Latin America and Caribbean, middle East and North Africa, Oceania and OECD members [31].

Figure 6:

Maternal mortality, life expectancy and births attended by skilled health personnel in high-income countries, lower-middle-income countries, low-income countries, Small Island developing states and sub-Saharan Africa [31].

Figure 6 is showing MMR per 100,000 livebirths based on the data from the country report on SDGs [27] in 10 countries with the highest absolute number of maternal deaths according to the data from the World Bank report as shown in Figure 4 [13]. It can be concluded that the progress has not been made in those countries in reaching the target MMR of 70 per 100,000 live births which was mentioned within the SDG 3.

Based on the methodology described in detail in the SDG report, the SDG dashboards have been constructed highlighting each region of SDG and income groups of countries strengths and weaknesses in relation to the 17 goals, presenting performance in terms of levels and trends [27]. Concerning the SDG 3, the results which have been achieved are presented in Table 3 [27].

If we look at the levels and trends of performance of the SDG 3, it can be concluded that only in one out of eight regions (OECD Countries) the challenges remain, but the performance of SDG 3 is on track, while it is stagnant in three out of eight and moderately increasing in four out of eight regions. These data are not encouraging in terms of achieving the targets which have been set at the beginning. In only one out of four income groups of countries (High-income) the performance of SDG 3 is on track, with remaining challenges.

COVID-19 pandemic and performance of Sustainable Development Goals (SDG)

The COVID-19 pandemic response was much better in the countries equipped with effective social protection and universal health coverage with universal access to key, especially digital infrastructure [27]. Good digital infrastructure enabled sustainable social services, payments, schooling, and health care during pandemic and particularly during the lockdowns, allowing effective working from home including all levels of education [27]. On the other hand, following the COVID-19 pandemic caused data gaps and time lags in official statistics in monitoring the progress of SDGs progress which highlighted the need for further investments in statistical capacity especially in lower-middle-income countries where the progress in targeting of SDGs transformations was the worse [27]. It is questionable why COVID-19 pandemic has underlined the value of timely data collection and loss of maternal and infant lives did not? Is saving the lives of COVID-19 victims more important than saving maternal and infant lives due to preventable causes [27]? More than five years after the adoption of the SDGs, considerable gaps in official statistics remain in terms of country coverage and timeliness for many SDGs [27].

Bad news about maternal mortality

From the recent data on MMR we can learn that Sub-Saharan Africa and Southern Asia accounted for approximately 86% (254,000) of the estimated global maternal deaths in 2017 [13]. Sub-Saharan Africa alone accounted for roughly two-thirds (196,000) of maternal deaths, while Southern Asia accounted for nearly one-fifth (58,000) [13].

Good news about maternal mortality

It so encouraging that between 2000 and 2017, Southern Asia achieved the greatest overall reduction in MMR: a decline of nearly 60% (from an MMR of 384 down to 157) [13]. Despite its very high MMR in 2017, sub-Saharan Africa as a sub-region also achieved a substantial reduction in MMR of nearly 40% since 2000 [13]. Besides that, four other sub-regions roughly halved their MMRs during this period: Central Asia, Eastern Asia, Europe, and Northern Africa [13]. Overall, the MMR in less-developed countries declined by a little under 50% [13].

Example of MMR reduction in India

India achieved reduction of the MMR by 77%, from 556 per 100,000 live births in 1990 to 130 per 100,000 live births in 2016 [28]. India’s present MMR is below the MDG target and puts the country on track to achieve the SDG target of an MMR below 70 by 2030. Four key actions are responsible for that achievement [28]:

1. Increased access to quality maternal health services,

2. allowing all pregnant women delivering in public health institutions to free transport and no-expense delivery, including caesarian section, with 75% of rural and 89% of urban deliveries attended by skilled provider,

3. significant emphasis on mitigating the social determinants of maternal health with 68% of women literate and decreasing number of adolescent marriages which is now 27% of women getting married before the age of 18, and

4. the government has put in substantive efforts to facilitate positive engagement between public and private health care providers, making healthcare for pregnant women especially at high-risk more accessible.

The global response to decrease maternal mortality in the world

In order to reduce MMR and to reduce incidence of preventable maternal deaths, Global Strategy for Women’s, Children’s and Adolescents’ Health stated that following steps should be made to improve maternal and infant health to rich SDG targets [11, 27]:

1. Addressing inequalities in access to and quality of reproductive, maternal, and newborn health care services;

2. ensuring universal health coverage for comprehensive reproductive, maternal, and newborn health care;

3. addressing all causes of MM, reproductive and maternal morbidities, and related disabilities;

4. strengthening health systems to collect high quality data in order to respond to the needs and priorities of women and girls; and

5. ensuring accountability in order to improve quality of care and equity.

The response of international learned societies to reduce maternal mortality

Work in progress

One of the good lessons came from Millennium meeting in 2000 year with all the remarkable recommendation made without one single perinatologists. However, good example of successful action, as already mentioned, is many years activity of Indian Society for Obstetrics and Gynecology resulting in very impressive reduction of MM in this huge country [32]. It is good news that perinatologists in the world did start a number of concrete actions for reduction of the global tragedy – MM and morbidity [29], [30], [31], [32]. It is very well documented in this article which is result of careful analysis of many good publications within important learned societies responsible for maternal health. Some of them are very well known to the readers of our journal. They include special issues of our journal dedicated to developing countries, several books on specific perinatal problems in developing countries, number of educational courses, schools and postgraduate studies [29], [30], [31], [32]. It is not in the scope of this paper to review all of them, but this might be subject of carefully prepared multicentric study on the results achieved. There is also biannual congress of perinatal medicine in developing countries dedicated completely to specific problems of poor countries [36]. Next one is very soon in Dominican Republic in June 2022 [36]. Many educational activities are done by Ian Donald Inter University School of Medical Ultrasound situated in 142 countries worldwide [37]. The School has its educational journal with almost 15,000 subscribers. At the world congresses of perinatal medicine held biannually there are always significant proportion of papers from developing countries. Many years ago, in July 2008, members of International Academy of Perinatal Medicine (IAPM) presented to the vice-president of the general assembly at the United Nations the declaration “Women and Children First” [38]. Most recently supreme scientific body in perinatal world IAPM started their own activities dedicated to reduction of MM and morbidity in developing world [39]. Figure 7 presents members of IAPM at Khartoum meeting dedicated to MM. First part of this long term planned actions is educational and the two meetings in Khartoum and Tuzla have been dedicated to teaching the teachers to be held in this challenging global action. In Sudan 68 participants led by distinguished colleague Ashmaig passed 2 days course and published the first impressive results in prestigious British Medical Journal. Meeting in Tuzla had 168 participants from 10 developing countries and a new one is planned for next year. Academy also stimulate research project on specific perinatal problems. The one very well organized is study of KANET test in the antenatal detection of neurological fetal disease. The results of this multicentric project are published in many high impact factor journals.

Figure 7:

Members of International academy of perinatal medicine at Khartoum meeting dedicated to maternal mortality.

But particular and most successful action was done through Matres Mundi and well-known professor José Maria Carrera from Barcelona [40]. We asked Carrera to give us short list of most successful Matres Mundi actions. They are:

1. Construction, equipping and inauguration of the “Mother and Child Specialized Center” hospital in Addis Ababa (Ethiopia), with a Maternity section (1,000 deliveries per year) and a Pediatrics section (with a Premature and Neonatal Intensive Care Center).

2. Building and equipment of two Maternity Homes in Rwanda. The maternity homes, that are close to the hospital, welcome days or weeks before delivery those pregnant women with obstetric problems or who live far from the hospital. Thus, obstetric problems, especially fistulas are avoided.

3. Help, with medicines, training courses for midwives and medical supplies, to the Saharawi refugees in the camps located next to the Algerian border.

4. Publication of a book of obstetric protocols, adapted to the African reality, called “Clinical Guidelines for Maternity Hospitals”, which has been sent to 64 African hospitals with the aim of improving their high figures for maternal and fetal morbidity and mortality (Figure 8).

Figure 8:

Typical maternity ward in sub-Saharan Africa.

Instead of conclusions

At the end we would like to quote Professor Mahmoud Fathalla, who claimed for better world for women while receiving the prestigious United Nations Population Award in 2009 [19]:

1. A world that treats women fairly and well, throughout their life course, as children, as adolescents, as young adults and as mature adults

2. a world in which the girl child is her brother’s equal in worth and in care, and, never again, will have her genitalia mutilated

3. a world in which the adolescent girl will be seen as an asset for a good investment in our future

4. a world in which no woman will have to risk her health and life because of an unwanted pregnancy, and in which women will be able to enjoy mutually fulfilling sexual relationships while capable of protecting themselves from disease

5. a world that will shed the shame, disgrace and the scandal of leaving mothers to suffer and die when they are fulfilling the noble task for survival of our species.

Indeed, in our great enthusiasm for high standard of perinatal care in the world we should not forget that the dominant features of reproductive health in most parts of the developing countries are high maternal death and morbidity rates, huge perinatal and childhood losses and high birthrates.