Introduction to Maternal Health
MATERNAL MORTALITY RATIO (MMR) is defined as “the number of maternal deaths during a given time period per 100,000 live births during the same time period. It depicts the risk of maternal death relative to the number of live births” (WHOWHO. n.d. “Maternal Mortality Ratio (per 100 000 Live Births).” World Health Organization. Accessed September 21, 2020. https://www.who.int/data/gho/indicator-metadata-registry/imr-details/26). The MMR in India is 113.Vital Statistics Division, Office of the Registrar General, Government of India. 2020. “SPECIAL BULLETIN ON MATERNAL MORTALITY IN INDIA 2016-2018.” https://censusindia.gov.in/vital_statistics/SRS_Bulletins/MMR Bulletin 2016-18.pdf.
INFANT MORTALITY RATE (IMR) is “the probability of a child born in a specific year or period dying before reaching the age of one and is expressed as a rate per 1000 live births” (WHOWHO. n.d. “Infant Mortality Rate (Probability of Dying between Birth and Age 1 per 1000 Live Births).” World Health Organization. Accessed September 21, 2020. https://www.who.int/data/gho/indicator-metadata-registry/imr-details/1.) The IMR in India is 32Vital Statistics Division, Office of the Registrar General, Government of India. 2020. “SRS BULLETIN.” SRS Bulletin. Vol. 53 no.1. https://censusindia.gov.in/vital_statistics/SRS_Bulletins/SRS Bulletin_2018.pdf..
Maternal and infant deaths occur most frequently in low-income countries. In 2017, the number of maternal deaths in high-income countries was just 11 per 1,00,000 live births, as against 462 per 1,00,000 live births in low-income countries. The probability that a 15-year-old woman will eventually die due to a maternal cause is 1 in 5,400 in high-income countries, whereas it is 1 in 45 in low-income countries (WHO 2019WHO. 2019. “Maternal Mortality.” World Health Organization. 2019. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality).
A large number of women die due to preventable or treatable complications that develop either during pregnancy or childbirth. In some cases, other complications may exist before pregnancy, but these tend to get exacerbated during pregnancy, especially if they are not identified and managed by the care provider (WHO 2019WHO. 2019. “Maternal Mortality.” World Health Organization. 2019. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality).
The major complications that account for nearly 75% of all maternal deaths include:
- severe bleeding (mostly after childbirth)
- infections (usually after childbirth)
- high blood pressure during pregnancy due to either pre-eclampsia or eclampsia
- complications from delivery
- unsafe abortions
Some of the major socio-economic factors that act as barriers to receiving or seeking quality care during pregnancy and childbirth include (WHO 2019WHO. 2019. “Maternal Mortality.” World Health Organization. 2019. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality):
- distance to healthcare facilities
- lack of information
- inadequate and poor-quality services
- prevalent cultural beliefs and practices
Quality of care is embedded in the right to health and is seen as a means to ensure that women and children are treated with dignity and in an equitable manner. It is defined as, “the extent to which health care services provided to individuals and patient populations improve desired health outcomes.” The essential components of quality care are: safe, effective, timely, efficient, equitable and people-centred. To facilitate universal health coverage, it is important for any healthcare system to deliver health services that meet the quality criteria mentioned above (WHO 2017WHO. 2017. “Quality, Equity, Dignity – Network for Improving Quality of Care for Maternal, Newborn and Child Health.” World Health Organization. https://www.who.int/maternal_child_adolescent/topics/quality-of-care/quality-of-care-brief-qed.pdf?ua=1.).
Disrespect and Abuse (D&A) of women during facility-based childbirth is also known as mistreatment, obstetric violence, or dehumanized care (Manning and Schaaf 2019Manning, Amy, and Marta Schaaf. 2019. “Disrespect and Abuse in Childbirth and Respectful Maternity Care.” White Ribbon Alliance. https://www.whiteribbonalliance.org/wp-content/uploads/2019/02/RMC_Disrespect_Abuse_Brief.pdf.). It can be defined as “interactions or facility conditions that local consensus deems humiliating or undignified, and those interactions or conditions that are experienced as or intended to be humiliating or undignified” (Freedman et al. 2014Freedman, Lynn P, Kate Ramsey, Timothy Abuya, Ben Bellows, Charity Ndwiga, Charlotte E Warren, Stephanie Kujawski, Wema Moyo, Margaret E Kruk, and Godfrey Mbaruku. 2014. “Defining Disrespect and Abuse of Women in Childbirth: A Research, Policy and Rights Agenda.” Bulletin of the World Health Organization 92 (12): 915–17. https://doi.org/10.2471/BLT.14.137869.).
Bohren et al. (2015Bohren, Meghan A., Joshua P. Vogel, Erin C. Hunter, Olha Lutsiv, Suprita K. Makh, João Paulo Souza, Carolina Aguiar, et al. 2015. “The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review.” Edited by Rachel Jewkes. PLOS Medicine 12 (6): e1001847. https://doi.org/10.1371/journal.pmed.1001847.) published a systemic review of 65 qualitative, quantitative, and mixed-methods studies, in which they proposed a seven-category model for classifying instances of Disrespect and Abuse. Manning and Schaaf (2019Manning, Amy, and Marta Schaaf. 2019. “Disrespect and Abuse in Childbirth and Respectful Maternity Care.” White Ribbon Alliance. https://www.whiteribbonalliance.org/wp-content/uploads/2019/02/RMC_Disrespect_Abuse_Brief.pdf.) summarize these as:
- physical abuse
- sexual abuse
- verbal abuse
- stigma and discrimination
- poor rapport between women and providers
- failure to meet professional standards of care (i.e. lack of informed consent and confidentiality, painful examinations and procedures or failure to provide pain relief, and neglect and abandonment)
- health systems constraints (lack of resources and infrastructure, lack of policies sanctioning inappropriate behaviour, a facility culture that promotes bribery and extortion; unclear fee structures; etc.).
As per Manning and SchaafManning, Amy, and Marta Schaaf. 2019. “Disrespect and Abuse in Childbirth and Respectful Maternity Care.” White Ribbon Alliance. https://www.whiteribbonalliance.org/wp-content/uploads/2019/02/RMC_Disrespect_Abuse_Brief.pdf.: “In light of the growing body of evidence of D&A, health and human rights organizations have deemed D&A during maternity care a violation of women’s human rights. When defining D&A, it is important to note that the absence of D&A does not equal respect; respectful, quality, woman-centered care requires conscious effort and should be prioritized by both care providers and health systems (Freedman & Kruk, 2014Freedman, Lynn P, and Margaret E Kruk. 2014. “Disrespect and Abuse of Women in Childbirth: Challenging the Global Quality and Accountability Agendas.” The Lancet 384 (9948): e42–44. https://doi.org/10.1016/S0140-6736(14)60859-X.). Thus, campaigners have called for respectful care and protection of all childbearing women, especially the marginalized and vulnerable, such as adolescents, minorities, and women with disabilities (Amnesty International, 2010AMNESTY, Amnesty International Publications. 2010. Deadly Delivery: The Maternal Health Care Crisis in the USA. London, UK: Amnesty International Secretariat. https://www.amnestyusa.org/files/pdfs/deadlydelivery.pdf.; White Ribbon Alliance, 2011WRA, and The White Ribbon Alliance for Safe Motherhood. 2011. “Respectful Maternity Care: The Universal Rights of Childbearing Women.” The White Ribbon Alliance for Safe Motherhood. https://www.whiteribbonalliance.org/wp-content/uploads/2017/11/Final_RMC_Charter.pdf.; World Health Organization, 2014WHO. 2014. The Prevention and Elimination of Disrespect and Abuse during Facility-Based Childbirth. World Health Organization. https://www.who.int/reproductivehealth/topics/maternal_perinatal/statement-childbirth/en/.). Although there is no consensus on what constitutes respectful care, the emerging RMC movement generally advocates a patient-centered care approach based on respect for women’s basic human rights and clinical evidence. The RMC Charter, a normative document that was developed collaboratively by researchers, clinicians, program implementers, and advocates, outlines a rights-based approach to many aspects of care.”
As described by the Lancet Maternal Health Series, “too little, too late” refers to the phenomenon where women do not have timely access to high quality services / resources / evidence-based care. This is seen in most countries and/or populations around the world, where social or demographic inequalities exist.
“‘Too much, too soon’ means care before, during and after childbirth that is too much, unnecessary, inappropriate, and possibly even harmful.” This type of care is increasing around the world, as more and more women are having institutional deliveries (Lancet 2020Lancet, The Lancet Maternal Health Series. 2020. “‘Too Much, Too Soon.’” 2020. http://www.maternalhealthseries.org/explore-the-series/too-much-too-soon/.).
Over-medicalization refers to unnecessary and unwanted interventions that women are subjected to during pregnancy, childbirth and the immediate postpartum period. While advancements in medical technology have helped save lives, they seem to have become the new norm in several parts of the world even when not needed. Thus, routine care or the natural birthing process has become unnecessarily medicalized.
Some of the most common unnecessary interventions include conducting episiotomies, unconstrained use of antibiotics, induction and augmentation of labour, as well as conducting C-Section deliveries, when it could have been a normal birth (Hodin 2017Hodin, Sarah. 2017. “Too Much Too Soon: Addressing Over-Intervention in Maternity Care.” MHTF Blog, 2017. https://www.mhtf.org/2017/04/28/summary-too-much-too-soon-addressing-over-intervention-in-maternity-care/.).
As per the National Family and Health Survey (NFHS) 4 conducted between 2015-2016, the C-Section rate in India is 17.2% (Radhakrishnan et al 2017Radhakrishnan, T., K.P. Vasanthakumari, and P.K. Babu. 2017. “Increasing Trend of Caesarean Rates in India: Evidence from NFHS-4.” Journal of Medical Science and Clinical Research 5 (8): 26167–76. https://doi.org/10.18535/jmscr/v5i8.31.). Like most countries across the world, we are also witnessing a rise in these rates, especially in private sector facilities.
To improve maternal health outcomes, barriers that limit access to quality maternal health services must be identified and addressed at the health system and the societal levels. It is therefore imperative to have a range of solutions including:
- raising awareness among women and their families about their rights
- empowering them to participate in decision-making and encouraging them to communicate about their choice of birth positions, birth companion, etc.
- providing access to good quality and impactful capacity building for all cadres of healthcare personnel on a regular basis
- conducting research studies that are evidence-based to guide clinical practices and programmes on the field
- reflect bottlenecks and policies that do not facilitate provision of quality of care within the healthcare system
- advocate for provision of quality care by developing global standards and implementing effective policies and programmes.