It’s Time To Talk About: Maternal Health Inequalities
Written By: Neha Maini
Edited By: Abigail Goh
“Sometimes the strength of motherhood is greater than natural laws.” – Barbara Kingsolver
Mothers are lauded globally for being strong and hardworking, with people expressing immense respect and love for their mothers. Mothers deserve respect, love, and appreciation, but too often it is forgotten that they deserve equal, safe healthcare.
In 2017, approximately 810 women died every day from preventable causes associated with pregnancy and childbirth – that is equal to 1 woman dying every 2 minutes. What is most distressing is that these deaths were all preventable, thus each of those women could have been saved with adequate and safe maternal healthcare. The main question is, why do these women die and how do we prevent this?
The Situation Globally
If we look globally, WHO has identified that the major complications accounting for 75% of these preventable deaths were:
Severe bleeding, especially postpartum (after childbirth)
Infections, especially postpartum (after childbirth)
High blood pressure during pregnancy
Complications from delivery
These complications unequivocally affect those in low-income countries; 94% of maternal deaths occur in low- and lower middle-income countries, with Sub-Saharan Africa and Southern Asia accounting for approximately 86%. Additionally, shocking statistics from UNICEF show that the lifetime risk of maternal death in West and Central Africa is 1 in 28 women, compared to 1 in 11,900 in Western Europe.
In Western and developed countries, these complications are incredibly rare due to the provision of medicines and adequate antenatal and postnatal care for pregnant women. For example, the risk of severe bleeding in the postpartum period can be significantly reduced by a simple injection of oxytocin into the mother immediately after childbirth. This is common practice across developed countries, such as the UK, and these resources and knowledge must be shared with countries at risk. Additionally, in high-income countries, over 90% of births are attended by a trained healthcare professional compared to less than half of births in low- and lower middle-income countries. It is known that the presence of a trained professional improves birth outcomes, and so the barriers to mothers in less developed countries attending maternal health services must be addressed to combat these issues of maternal mortality and poor health. Research has found that a lack of woman’s autonomy is associated with reduced use of antenatal care services, therefore the cultural beliefs that often stop women from asking for help must be addressed.
Whilst discussing the tragedy of maternal mortality worldwide, it is important to also praise the improvements that have been documented. From 2000-2017, South-Asia reported a 59% overall reduction in maternal mortality rates, the highest global reduction in that time period. This is an incredible achievement and must be praised, especially in a setting where resources and support for women are not always available. One scheme that likely contributed to the improvement in maternal mortality rates in South Asia, is the ASHA scheme in India which launched in 2005. ASHAs (‘Accredited Social Health Activists’) are female community health-workers deployed by the government who receive training to improve health education and promotion within their communities. Some of their tasks include encouraging family planning and motivating women to give birth in hospitals, which are key drivers for improving maternal health and reducing maternal mortality rates.
South East Asia
Focussing directly on South East Asia, the rate of maternal ill-health and mortality is still tragically high. In 2010, the UNFPA reported that 150 women died per 100,000 births in the Asia and Pacific region from complications associated with pregnancy and childbirth. Within this region, there are flagrant differences between subregions; in South Asia, 230 women die per 100,000 births compared to 150 women in South-East Asia, and 37 women in East Asia. These statistics show the terrifying reality of millions of women living in the Asia and Pacific region, and shows clear inequalities in maternal healthcare within the region itself. The subregional differences are further corroborated by research published in the Lancet which found that, within South East Asia, there are 3 major patterns of maternal and child mortality. These patterns were found to be: early, rapid downward trends (Brunei, Singapore, Malaysia, and Thailand); initially high declines (sustained by Vietnam but faltering in the Philippines and Indonesia); and high initial rates with a downward trend (Laos, Cambodia, and Myanmar). The findings from this article led to a recommendation by the authors which is clear: “There is a need for stronger regional cooperation through the Association of Southeast Asian Nations to provide support to countries that need to accelerate progress to meet the MDGs”.
Despite the obvious tragedy of maternal mortality and ill-health in South East Asia, there is some hope following the announcement in March 2021 of a new taskforce focussing on maternal and child health in Singapore. The taskforce will encompass multiple agencies with the aim of ensuring good maternal physical and mental health to ensure good health and development outcomes in their children.
If we look locally in the UK, the trends and reasons underlying maternal mortality are highlighted by MBRRACE-UK’s confidential enquiries. The most recent report focussed on 547 women who died during, or up to 1 year after, pregnancy between 2016-2018 in the UK. The report identified that the top causes of maternal mortality in the UK are:
Heart disease (23%)
Blood clots (15%)
Mental health conditions (13%)
The report importantly highlighted a concerning rise in maternal mortality as a result of epilepsy (Sudden Unexpected Death in Epilepsy).
However, if we look beyond medical and physiological causes of maternal mortality and ill-health, the MBRRACE UK report highlights key discrepancies between groups of women, as well as the importance that societal factors play on maternal health. In the UK, Black women are 4 times more likely to die in pregnancy than white women, and Asian women are 2 times more likely. Additionally, MBRRACE has highlighted a constellation of biases which highlights systemic and structural racism that prevent marginalised women with complex and multiple problems from receiving the care they need. From this report, it is clear that despite higher-income countries having resources to reduce maternal mortality rates, more effort now needs to be taken to improve intersectional factors and biases that contribute to maternal mortality.
Whilst maternal health and the inequalities mothers face are not new, the discussions surrounding it in the mainstream media are. All over the world, organisations are being set up to combat maternal health inequalities, specifically maternal mortality. For example, in the UK, the organisation “FIVEXMORE” campaigns to combat the inequalities faced by pregnant Black women in the UK that results in them being 4 times more likely to die in pregnancy. Additionally, the UK government recently opened a call for evidence to gain insight into women’s experience of healthcare in the UK, including maternal health. This will hopefully guide changes within the UK healthcare system to improve maternal healthcare.
Globally, Goal 3 of the UN’s Sustainable Development Goals aims to reduce the global maternal mortality rate to less than 70 per 100,000 births, with each country reducing their maternal mortality rates to less than two-thirds of their baseline in 2010. To achieve this goal, the UN aims to increase the number of births attended by skilled birth attendants and reduce the number of adolescent pregnancies. Strides have been taken to reach these goals, as 81% of births were attended by a skilled birth attendant worldwide between 2014-2019, compared to just 64% between 2000-2005.
There is a long way to go to improve maternal healthcare globally, and substantial financial and social investments need to be made to achieve real change. Additionally, the intersectionality affecting inequalities in maternal healthcare must be addressed rather than be swept under the carpet. However, not all hope is lost. In the last couple of years inequalities in women’s health, and specifically maternal healthcare, have made their way into mainstream media so wider audiences are being educated on the issues faced by mothers worldwide. Whilst this itself will not solve the problem, it’s a significant step in encouraging the public and their governments to do better, and improve the lives of pregnant women and mothers worldwide.
It’s important for all parents-to-be to educate themselves about childbirth to ensure they can advocate for themselves in healthcare settings! Below are some links to educational resources:
Choices In Childbirth:
choicesinchildbirth.org; provides educational resources for expectant mothers
www.bestbeginnings.org.uk/black-and-ethnic-minority-families; provides educational links to resources for different minority groups
birth-ed.co.uk/; provides paid-for courses in the UK and free online educational resources
belovedbumps.sg/; provides courses & online resources for mothers-to-be in Singapore