Unequal access and low quality of maternal health care hampering progress towards SDGs
Progress has been patchy and authors warn against poor quality care with rising rates of over-medicalisation, too few trained staff or basic resources in many regions.
Each year, about 210 million women become pregnant and about 140 million newborn babies are delivered. While progress has been made in reducing maternal mortality globally, differences remain at international and national levels. The gap between the groups of countries with the lowest and highest rates of maternal mortality has doubled between 1990 and 2013 (paper 1, fig 3).
Ahead of the UN General Assembly, The Lancet publishes a new Series on Maternal Health. Six papers cover the epidemiology of maternal health, the current landscape of maternal health care and services in both high and low income countries, and future challenges and strategies to improve maternal wellbeing.
"In all countries, the burden of maternal mortality falls disproportionately on the most vulnerable groups of women. This reality presents a challenge to the rapid catch-up required to achieve the underlying aim of the Sustainable Development Goals (SDGs) - "to leave no one behind"", says Series author Professor Wendy Graham, London School of Hygiene & Tropical Medicine, London, UK .
Approximately one quarter of newborns worldwide are delivered in the absence of a skilled birth attendant (paper 3), and while an increasing number of mothers are using birth facilities, the quality of care varies widely. Two broad scenarios describe the landscape of poor maternal health care - the absence of timely access to quality care (defined as 'too little, too late') and the over-medicalisation of normal antenatal, intrapartum, and postnatal care (defined as 'too much, too soon'). The problem of over-medicalisation has historically been associated with high-income countries, but it is rapidly becoming more common in low and middle income countries, increasing health costs and the risk of harm. For instance, 40.5% of all births are now by caesarean section in Latin America and the Caribbean (paper 2, panel 1).
A total of 51 evidence-based guidelines exist worldwide, yet the authors identify wide variations in terms of adherence to recommended practice. While facility and skilled birth attendant deliveries are increasing in many low income countries (paper 3, fig 2), the authors say that phrases such as 'skilled birth attendant' and 'emergency obstetric care' can mask poor quality care. Additionally, many birth facilities lack basic resources such as water, sanitation and electricity (paper 3, fig 4). The authors warn that measuring progress via that the current indicator of skilled birth attendant coverage is insufficient and fails to reflect the complexity of circumstances.
"It is unethical to encourage women to give birth in places with low facility capability, no referral mechanism, with unskilled providers, or where content of care is not evidence-based. This failing should be remedied as a matter of priority," adds Series author, Professor Oona Campbell, London School of Hygiene & Tropical Medicine.
In high-income countries, rates of maternal mortality are decreasing but there is still wide variation at national and international level. For instance, in the USA the maternal mortality ratio is 14 per 100,000 live births compared to 4 per 100,000 in Sweden (paper 4, case studies). The majority of births in high-income countries take place in hospitals (eg, 2% of all births take place at home in the UK) and the vast majority of newborns are delivered by a skilled birth attendant. However, the authors warn that not all care is evidence based, and improved surveillance is needed to understand the causes of maternal deaths when they do occur. Additionally, they point to new challenges in delivering high quality care including the increasing age of pregnancy (paper 4, fig 2), and higher rates of obesity.
The authors of the Series identify five key priorities (paper 6) that require immediate attention in order to achieve the SDG global target of a maternal mortality ratio of less than 70 per 100,000 live births. These include prioritising quality maternal health services that respond to local needs, promoting equity through universal coverage of quality maternal health services, improving the health workforce and facility capability, and guaranteeing sustainable financing for maternal and perinatal health.