Guest Editorial • PerinatalMary C. Brucker, PhD, CNM, FACNM

Mothering the WorldImproving Global Maternal Health

The future of a society is said to be illustrated inhow it treats the most vulnerable of its members.

Although the author of this statement is in dispute,the concept itself is well accepted. Among emergingnations, maternal child health encompasses the mostvulnerable citizens. Since life expectancy tends to beshorter than that in developed countries, the majorityof the population in developing countries tends to beyoung, ranging in ages from being intrauterine to youngadolescents. The latter includes the young women whoall too frequently become the mothers in the coun-try. Thus, maternal child health tends to be the publichealth crisis of poor nations.

POPULATION PYRAMIDS

A population pyramid illustrates the ages of societalmembers by graphing the number of individuals withinan age group. Developing countries most frequently arecharacterized by an expansive population pyramid or apopulation that has a broad base because of the highproportion of children accompanied by a rapid pop-ulation growth, a high death rate, and general shortexpectancy.1–3 This pattern is commonly found amongeconomically disadvantaged countries. Figure 1 pro-vides an example of a pyramid for Uganda, demonstrat-ing the increased number of youth.4

In Uganda, approximately half of its population isyounger than 15 years.5 Unplanned births in Ugandarose from 29% in 1995 to 38% in 2000–2001, accord-ing to a 2006 study by the Guttmacher Institute andMakerere University.6 In addition to Uganda, more than50 other countries have populations in which greaterthan 40% are younger than 15 years. All of these coun-tries are in Africa or the Middle East and have high birthrates, as well as high perinatal and maternal morbidityand mortality risks when compared with industrializednations.

UNITED NATIONS MILLENNIUMDEVELOPMENT GOALS

In September 2000, a United Nations Summit cul-minated in the publication of the MillenniumDeclaration.7 This document was adopted by ap-proximately 200 nations, signed by more than 140heads of states and governments and was the basisof 8 goals designed to be achieved by the year 2015.The Millennium Development Goals (MDGs) werewritten to respond to the world’s main developmentchallenges and were subdivided into 21 targets with 60measurable indicators.8 The goals are found in Table 1and the targets in Table 2. The latter are regularlymonitored for the sake of evaluation.9

Promoting improvement of maternal health in any so-ciety is a complex issue. Unlike other global challengessuch as eradicating polio, no vaccine exists to decreasematernal mortality. Developed countries may desire touse their resources to provide funding to improve carein poorer countries because of humanitarian concerns.Yet a nation with a history of colonialism may viewhelp from developed countries negatively for fear of re-peating their previous subordinate relationships. Othercountries, both developed and emerging, may have ob-stacles for sharing wealth, including unnecessary bu-reaucracy or even corruption.

Although Goal 5 is specific to maternal health,such improvements are impossible without being in-tertwined with the other goals. Figure 2 is an exampleof a conceptual framework as created by the UnitedNations Children’s Fund (UNICEF) in an attempt toidentify some of the various factors that affect maternalhealth.10 Poverty and hunger have been well associatedwith poor pregnancy outcomes. Gender discriminationis an obstacle for women to obtain appropriate health-care. Education is another influence. Even though 99%of women dying in childbirth are found in emerg-ing countries,11 a woman from any nation who has a

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Figure 1. Population pyramid for Uganda. From US Census Bureau (http://www.census.gov/ipc/www/idb/country.php).

secondary education has a marked decrease in mater-nal and perinatal risk.12 Concomitant conditions suchas human immunodeficiency virus and tropical dis-eases present special considerations for women, es-pecially during pregnancy. Therefore, simply provid-ing funding for “delivery of perinatal healthcare” isinsufficient for sustainable improvement in maternalhealth.

However, Goal 5 does provide a common lexicon forinternational endeavors as well as a forum for sharingof information and dissemination of information aboutboth successes and failures. Studies are now being pub-lished referencing the goal and its benchmarks so thatthere can be some valid comparisons.13–15

Table 1. UN Millennium Development Goalsa

Goal 1: Eradicate extreme poverty and hungerGoal 2: Achieve universal primary educationGoal 3: Promote gender equality and empower womenGoal 4: Reduce child mortalityGoal 5: Improve maternal healthGoal 6: Combat HIV/AIDS, malaria and other diseasesGoal 7: Ensure environmental sustainabilityGoal 8: Develop a Global Partnership for Development

aFrom reference 7.

SPECIFIC STRATEGIES FOR MDG 5

The majority of global initiatives that are being re-ported in response to MDG 5 are focused on intra-partum events such as management of preeclamp-sia, postpartum hemorrhage, and infection.16–18 Activemanagement of third stage often is promoted in an at-tempt to decrease bleeding. Training of traditional birthattendants and midwives is a strategy to increase thenumbers of skilled attendants.

Table 2. Targets associated with Millennium De-velopment Goal 5

Target 5a: Reduce by three quarters the maternal mortalityratio

5.1 Maternal mortality ratio5.2 Proportion of births attended by skilled health

personnelTarget 5b: Achieve, by 2015, universal access to

reproductive health5.3 Contraceptive prevalence rate5.4 Adolescent birth rate5.5 Antenatal care coverage (at least one visit and at

least four visits)5.6 Unmet need for family planning

a From reference 7.

108 Journal of Perinatal & Neonatal Nursing/April–June 2010

Figure 2. Conceptual framework for maternal and neonatal mortality and morbidity. From UNICEF (http://www.unicef.org/sowc09/docs/SOWC09-Figure-1.7-EN.pdf).

Few global strategies appear to target preconcep-tional health in poorer nations, although this interven-tion appears well aligned with maternal health.19 Ahealthy woman is most likely to continue to be healthyduring pregnancy and have an uncomplicated birth ofa healthy newborn.20 Family planning enables womento become pregnant when they are most likely to haveoptimal maternal and child outcomes.21

Unlike women in the United States, where many ex-perts note that the rate of cesarean births in excessof 30% is likely unwarranted, women in developingnations often do not have access to such a deliveryroute when it truly is needed. Therefore, emergency

obstetrical care is another critical tactic to improve ma-ternal (and child) health.22

INTERNATIONAL ENDEAVORS ANDPARTNERSHIPS

Addressing MDG 5 has mobilized some national groupsand promoted collaboration among many others. Mul-tiple nongovernmental organizations that may havebeen present in sections of the world for decadeshave been newly rediscovered. A few examples ofvarious groups include the Pakistan National Forum

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on Women’s Health, whose goals include eradica-tion of obstetrical fistulas23 as well as training nurs-ing and midwifery tutors for the provinces in thecountry.24 Jhpiego, affiliated with Johns Hopkins Uni-versity, has a new project that focuses on preven-tion, detection, and treatment of eclampsia in 11 Asianand African countries and $5 million is earmarkedfor funding as announced at a 2009 meeting of theClinton Global Initiative.25 Qifang26 is an organizationthat targets young women in Shannxi, China, and usessocial lending and a Web platform to finance their col-lege costs in an effort to have them become commu-nity leaders. The Bill and Melinda Gates Foundationis supporting a maternal health task force to improvematernal health worldwide, especially by conveningstakeholders in the area in order to decrease dupli-cation, build consensus, and share information.27 TheWhite Ribbon Alliance is a group of nations and oth-ers who focus on decreasing maternal mortality in theworld.28,29

The US Agency for International Development is agovernmental agency that provides funding for inter-national needs, including maternal health and partner-ing with faith-based groups.30 Although not specific tomaternal health, the World Bank provides loans to de-veloping nations at low rates to encourage economichealth in a country. UNICEF spends most of its bud-get on health issues. The Rockefeller Foundation, oneof the oldest and best-known philanthropic organiza-tions, is actively involved in projects such as populationresearch. The Project Health Opportunities for Peo-ple Everywhere is better known as Project Hope andhas one of the largest fundings for international care,including women’s health. Among faith-based organi-zations that have partnered with the United NationsPopulation Fund targeting women’s health are WorldVision, Islamic Relief, Adventist Development and Re-lief Agency, and the Salvation Army. A myriad numberof other faith-based groups are involved with medicalmissions worldwide.

When disasters occur in developed nations, theresults can be devastating, especially for pregnantwomen. After Hurricane Katrina struck Louisiana andindividuals had to migrate from the area, the verypreterm birth rate soared in nearby Alabama.31 How-ever, in emerging nations with low resources and lack-ing clean water, roads, and other infrastructure, suchan event can be devastating. The Nobel Peace Prize–winning Medecins Sans Frontieres (Doctors WithoutBorders) has teams that include midwives and fre-quently can be found in areas of natural or manmadedevastation.

A call advocating that professional health organiza-tions be actively involved in global maternal health hasbeen articulated.32 Such activities include the Interna-tional Federation of Obstetrics and Gynecology Savethe Mothers Initiative. The American College of Nurse-Midwives has been working globally for more than 3decades and has specific programs to teach life-savingskills for midwives and obstetrical and neonatal nursesin poor-resource areas and home-based life-saving skillsfor communities in which home birth is the norm.33

This organization is also assisting with midwifery as-sociations through its Global Outreach department inAfrica and the Middle East in an attempt to strengthenthem, and therefore, the access and care women inthose areas have with skilled providers.34

A recent New York Times bestseller by 2 Pulitzer-winning journalists, Kristoff and WuDunn, has broughtthe plight of women to a new market of Americanreaders.35 Members of book clubs as well as viewersof television interview programs have learned aboutthe stories of women in other countries. These storiesinclude those of women sold into sex slavery, mater-nal mortality, and domestic violence in Africa and Asia,as well as tales of hope and promise of education of girlsand women. The use of personal stories make issuesreal to the readers and also are accompanied by listsof programs and groups to which contributions can bemade, either monetary or in volunteer time.

The sheer number of groups desiring to improveglobal maternal health demonstrates the importanceof doing so. The health of women has a profoundeffect on children and families. The phrase “HealthyWomen, Healthy World” is found in many publicationsand Web sites in an attempt to capture the importanceof women’s health in a user-friendly slogan. Many ofthe maternal health projects have been undertaken inresponse to MDG 5 and only preliminary findings ex-ist. Older projects often were initiated in a desire tohelp and rarely had an evaluation plan associated withthem.

GLOBAL LESSONS FOR LOCAL ACTION

Not only do projects help women in emerging coun-tries, but there can be lessons of value for developed na-tions. Developing nations do not have exclusive rightsto vulnerable women or poor maternal health. It maybe argued that much of what is being implemented inemerging nations also could be used domestically. In-fant mortality rates note that the United States is rankedlower than Cuba, Poland, or Hungary, as noted in

110 Journal of Perinatal & Neonatal Nursing/April–June 2010

Figure 3. Infant mortality rates, selected countries 2005. From Health, United States, 2008 (http://www.cdc.gov/nchs/data/databriefs/db23 fig1.png).

Figure 3.36 Women of color are 3 to 4 times as likelyas white, non-Hispanic women to die during childbirth(see Fig 4).37 Racial disparities within such a devel-oped country demonstrate a need to improve maternalhealth within the US borders as well as globally.38

Caring for women globally also enables a venue foreducation of students from North America. Advan-tages to these learners include exposure to other cul-tures and management in low-resource areas. Both ofthese skill sets are valuable to healthcare providersdomestically.

THE PAST AND FUTURE

Humanitarian efforts of individuals from more prosper-ous countries to help others in poorer nations are notnew. Some actions, especially from the last century,continue to operate such as the hospital establishedby Albert Schweitzer in Gabon, Africa. Other projectssuch as the healthcare clinics started by Tom Dooleyin mid-century Laos Asia fell victim to war and strifein the country. However, his legacy lives on in otherprojects he inspired as the United States Peace Corpsand various other endeavors as far afield as a large or-phanage in rural Bao Lam Vietnam. In the 21st century,the world has flattened, making communication andtravel easier than ever before. These positive changesare accompanied by some challenges. Small groupsmay find themselves with plans to designate adoption

of a specific poor area, especially in Africa, Asia, orLatin America. Upon arrival of their team, they findthat other well-meaning groups already have startedprojects. Therefore, partnerships, especially betweengovernments and nongovernmental organizations, arethe most likely groups to be successful as they tend toincrease communication, decrease duplication, maxi-mize funding, and facilitate sustainability.

Sustainability is a major issue that can be overlookedby small groups focused on immediate needs. As part

Figure 4. Maternal mortality rates by racial and ethnicgroup, United States, 2004. Annual number of deaths dur-ing pregnancy or within 42 days after delivery per 100 000live births. From Centers for Disease Control and Preven-tion, National Center for Health Statistics and Division ofReproductive Health.

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of sustainability, education of community members toassume roles in nursing, midwifery, or other leadershippositions contribute to long-term societal changes andimprovement in maternal health. Such education ad-vances the status of women and promotes individualswithin the culture.

In summary, maternal health is an integral compo-nent of a nation’s health and, combined with child

health, comprises the most important health issues ofa developing country. Safeguarding mothers directly in-fluences generational health. After all, the hand thatrocks the cradle rules the world.

—Mary C. Brucker, PhD, CNM, FACNM

Baylor University Louise HerringtonSchool of Nursing, Dallas, Texas

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