What is already done by different societies in reduction of maternal mortality? Are they successful at all?

Introduction

Maternal mortality remains an unsolved problem of modern perinatology. According to World Health Organisation, even today the estimation of more than 800 women/day dying as a result of pregnancy and parturition complications remains a tremendous fact, that if calculated annually, gives an overall number of approximately 300,000 deaths per year [1]. As it is very well known, the issue of maternal mortality is much more severe in the developing world, where the overall deaths during pregnancy and labor have been calculated to account for 99% of the worldwide deaths, with the risk being 97 times higher than in Europe or North America [2]. The causes of more than half cases of maternal mortality are post-partum haemorrhage (27%), severe pre-eclampsia and eclampsia (14%), infections and sepsis during antepartum or postpartum period (10%), and intrapartum complications such obstruction and secondary arrest of labour especially in multiparous women (8%) [3]. Other causes involve complications with pregnancy termination (at different stages of pregnancy) and of pre-existing medical conditions and infections that are not managed accordingly during pregnancy, leading to catastrophic consequences, with HIV and malaria remaining leading causes. It is obvious that most of these deaths would never have occurred if these women had their antepartum care and gave birth in a developed country, meaning that many of these unfortunate deaths could have been avoided. It has been calculated that if all countries worldwide had the same standards of care during pregnancy and labour, such as the ones in developed countries, maternal death would have been annihilated [4]. This fact has alarmed many scientific societies that have developed strategies and activities in order to face this huge problem of maternal mortality, especially in developing countries. The aim of these actions is focused mainly in:

1. Better training of medical personnel.

2. Providing sufficient medical equipment and drugs.

3. Offer updated guidelines, better contraception, and safer termination of pregnancy.

But in order not to be pessimistic, according to United Nations report in 2015, a 44% decrease in the rate of maternal mortality has been achieved in a period of 25 years (from 1990 to 2015). And even though this achievement represents a very important reduction, there is still a long way to go [5].

One of the main reasons for maternal mortality in low-income countries, is the fact that these countries lack of many sources, an issue that can be solved with the help of medical and scientific societies. However even when looking at countries with similarly low income, differences can be identified in their maternal mortality rates. In these countries the living conditions, the health care system and the training system of medical stuff, is the reason that declined their maternal mortality rates. This knowledge could possibly give us a leading point to further improve maternal mortality in other financially-similar countries. Of all human development indicators, the maternal mortality ratio shows the greatest discrepancy between developed and developing countries. South Asia has both the largest number of women of reproductive age and the largest number of maternal deaths, followed by Africa [1, 4].

Causes of maternal death

Maternal death is a detrimental incidence that in order to avoid, understanding its’ possible causes represents the greatest obstacle. Figure 1 shows the domino effect that follows a maternal death, as an incidence like that affects not only women, but her family and community equally. Not to mention women who fortunately escape from maternal mortality but suffer from severe maternal morbidity due to the same reasons.

Figure 1:

Socioeconomic effects of maternal mortality (the domino effect).

Seventy three percent of maternal mortality is attributed to direct obstetric causes, with maternal haemorrhage and hypertension being the leading causes of maternal mortality in developing countries [6].

What are the reasons for the inadequate antepartum, intrapartum and postpartum care?

In order to understand the reasons of increased maternal mortality rates in developing world, it is important to compare the care that women receive in developed world to that in developing countries. It is taken for granted that women in Europe and North America will regularly attend an antenatal clinic and they will be guided and delivered by adequately trained medical personnel (doctor or midwife) in order to have a proper postpartum check-up. This is something that is achieved only in 40% of pregnant women in developing countries, as for the majority of pregnant women in these areas of the world, the system fails to provide the standard care during pregnancy, labour and postpartum period (according to the worldwide guidelines), mainly due to lack of trained medical personnel and technical reasons such as inaccessibility to the hospitals, cultural issues and lack of information to women about their options.

The inadequate healthcare to pregnant women can largely be attributed to a delay in reaching the appropriate healthcare system. The reasons for such delays can be divided in three categories [10].

The rates of maternal mortality in Europe

During the past 40 years, Europe has achieved a significant decrease in maternal mortality rates, with the most significant decrease being achieved from 2000 to 2015, from 33 to 16 deaths per 100,000 live births. However, there are still groups of people within Europe that suffer unacceptably high maternal mortality rates, especially women of “non-western” origin, or women in eastern European countries such as Belarus, Estonia, Latvia, and Slovenia. The lowest rates of maternal mortality are seen in southern European countries (Spain, Italy, and Greece), followed by those of central Europe (Germany and Sweden). If we isolate maternal age as a risk factor for maternal mortality, the rate of maternal mortality is doubled for women older than 35 years. Delivery method is also a significant risk factor, as operative vaginal deliveries and emergency caesarean sections, carry a much higher risk of maternal mortality. It is impressive that elective caesarean section does not increase the risk of maternal mortality [14].

It is worth mentioning that even in advanced health care systems like in Europe, there is still insufficient recording of maternal deaths. It is also important to mention that the numbers in maternal mortality rates in Europe, may be different than in developing countries, but the causes of maternal mortality are the same all over the world, and so there is always a reason for improvement. Haemorrhage is the main cause of maternal mortality even in Europe (13.1%) followed by thromboembolic events (10.1%), complications associated with hypertensive disease of pregnancy (9.2%) and amniotic fluid embolism (10.6%) ([15], Figure 2).

Figure 2:

Maternal mortality in Europe in 2016 [16].

Discussion

Almost 300,000 maternal deaths occur per year worldwide, and the vast majority of them – with a small exemption of 0.8% – take place in developing countries. In the era of subfertility, developing countries such as South Asia have the largest number of women of reproductive age and at the same time the largest number of maternal deaths, followed by Africa. The estimated cumulative lifetime risk of dying from pregnancy related causes is 1 in 21 for Africa, 1 in 54 for Asia, 1 in 73 for Latin America, and 1 in 140 for the Caribbean, compared with 1 in 6,400 for the USA and less than 1 in 10,000 for Northern Europe [1, 4, 5]. The lifetime risk of maternal mortality in Nigeria is 1 in 20, over 1,000 times that in Sweden, whereas for perinatal mortality rates, the disparity between the two countries is 18-fold (5 per 1,000 vs. 90 per 1,000) [17, 18]. These incredible differences reflect the discrepancy in socio-economic development among these countries, and with such huge discrepancies in financial background, proper healthcare system cannot exist. The causes of maternal mortality are very well known both in developed and developing countries: maternal haemorrhage (25%), infection (15%), eclampsia (12%), obstructed labour (8%), unsafe abortion (13%), indirect causes like anaemia, malaria or heart disease (20%), or other direct causes like ectopic pregnancy, embolism and anaesthesia-related causes. If mother is already anaemic and suffers severe bleeding during or after labour, it is more likely that she will suffer the consequences of bleeding [19]. If a mother is anaemic and she is located in Europe, it is more likely that she will detect her anaemia through blood tests during prenatal monitoring, and will have the opportunity to improve it by receiving different forms of iron supplements. An anaemic woman in a developing country may not have the same monitoring, and due to malnutrition anaemia will get worse, so that any form of bleeding may not be able to be counterbalanced. Access to health care facilities and medical personnel in developing countries is a big issue, as pregnant women have 50% less chance of delivering with a properly trained attendant, inside a medical facility. Women are more likely to give birth at home, and if needed to be transferred to a hospital, she may have to be transferred by the public means of transportation. Last but not least is the fact that maternal deaths are responsible for neonatal mortality and morbidity as many neonatal deaths are the result of poor maternal health and inadequate care during pregnancy, delivery and the critical immediate postpartum period [1, 4].

Perinatal mortality reflects the level of overall medical care and standards of the society. In 1987 the World bank, WHO, and United Nations Fund for Population Activities sponsored a ground-breaking International Safe Motherhood Conference in Nairobi, Kenya [20]. Out of that event grew collaboration between the World Bank, UN Organizations and private institutions, to foster research on maternal mortality and to aim on reduce maternal deaths by half by the year 2000. Subsequently, the Prevention of Maternal Mortality Network (PMM) was established to engage the capabilities of leading physicians, midwives, and social scientists within Africa, in research for the causes of maternal mortality and morbidity in their region, and to take responsibility for advocating or implementing programs to promote maternal health. The results of these efforts have included small but successful programs, such as essential obstetric functions at first-referral level, greater use of the partogram, and maternity waiting facilities. The causes of maternal mortality have been clearly identified and documented and the effort should now be directed to an improvement of perinatal care, introduction of simple and clear protocols, education and training of medical personnel [21].

For most women the period of pregnancy and delivery is a period of happiness and joy. However, many women suffer from unfortunate events, that could have been avoided. What is more the issue of maternal mortality, devastating as it can be, is that most of these maternal deaths occur in low-income countries, with inadequate system to support families and their children. Indeed, progress in lowering maternal mortality ratios has been made, but mainly in high income countries, and of course further improvement is more than necessary. In low-income countries, training of medical stuff is needed, but this would not be enough without the additional support in resources and medical equipment, and of course accessibility of pregnant women to hospitals – not to mention the right of women to proper information about contraception and family planning [12].

In 2000, the average risk of dying during pregnancy or childbirth in the developing World was 450 per 100,000 live births, a number that increases with parity. The risk of maternal mortality can reach 1 in 16 in sub-Saharan Africa, compared with 1 in 3,800 in the developed World. The huge difference between these 2 numbers, shows how simple methods, such as easy access to hospital, are of great importance in order to face emergency situations in labour and pregnancy, while simple contraceptive methods, can save lives and decrease significantly maternal mortality rates [15].

The example of Bangladesh is truly worth mentioning. They managed to reduce maternal mortality by investing in better training in obstetrical emergencies, by improving access to health care facilities and by improving education of young women on family planning and contraceptive methods [22]. What is more in Egypt, maternal mortality was decreased by 50% in less than 10 years. This success story was a result of investment in better training of medical stuff in obstetrical emergencies and family planning. This is an excellent example that financial background is not the only reason for perinatal mortality, otherwise all countries with same income, would have the same percentage of maternal mortality. Egypt has maintained lower levels of maternal mortality rate compared to Indonesia and Namibia, that are countries with very similar financial background.

The most severe problem remains in sub-Saharan Africa, where during the last few years there have been no major improvements in maternal mortality rates, in contrast to other low income areas, such as Northern Africa, Eastern and Southern Asia, that are still having the lowest level of professional care at birth worldwide [1, 4, 15].

Conclusions

Maternal mortality is a very good indicator that reflects the level of a health care system, but also represents the everyday socioeconomic difficulties that a society has to deal with, in order not only to avoid further perinatal adverse outcomes, but also retain a quality of living for both men and women. The knowledge to improve maternal and perinatal health is not always obvious, and it is mainly a job of medical health cares to disseminate it, since health care professionals have an obligation to share the knowledge, especially today with the help of advanced technology. There is a need for clear and strict protocols for the management of complications of pregnancy labour, that are easily accessible affordable by all citizens. Structured training is necessary while regular seminars on training medical professionals in low-income countries are needed today more than ever. Societies and colleges such as the American College of Obstetrics and Gynecology and the Royal College of Obstetricians and Gynecologists have developed clear protocols and guidelines that have specific training programs not only for general obstetrics and gynaecology, but also for subspecialties and special interests. In other countries similar strategies for training have been followed and being advancing. The need for training in obstetrics and perinatal medicine is very big and the means to offer this training should be accessible to all countries.