United Nations Population Fund

Reducing Maternal Mortality in Developed Countries Director: Verena Martínez Agraz Moderator: Stephanie Furreta Bento

INTRODUCTION The “United Nations Population Fund is the United Nations sexual and reproductive

health agency. The UNFPA mission is to deliver a world where every pregnancy is wanted,

every childbirth is safe and every young person's potential is fulfilled. Seeing that it is possible

to accelerate the decline, countries have now united behind a new target to reduce maternal

mortality even further. One target under Sustainable Development Goal #3 is to reduce the

global maternal mortality ratio to less than 70 per 100 000 births, with no country having a

maternal mortality rate of more than twice the global average. The United Nations sexual and

reproductive health agency provides healthcare for women in more than 150 countries. “The

agency focuses on the health of pregnant women all around the world, specially those who are

in life threatening situations due to pregnancy, but also efforts to end with child marriage and

other issues related to the reproductive and sexual health of society.” (UNFPA, 2018).

Maternal Mortality is defined as “the death of a woman while pregnant or within 42

days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from

any cause related to or aggravated by the pregnancy or its management but not from accidental

or incidental causes” (World Health Organization, n.d.). Maternal Mortality has been an

important issue since the beginning of times but lately, rates have been increasing in a

considerable way: “According to the World Health Organization, approximately 830 women

die every day from preventable causes related to pregnancy and childbirth (World Health

Organization, 2018). Furthermore“more than 300,000 women died in 2015 of complications

from pregnancy and childbirth” (United Nations Foundation, n.d.).

And although this issue is even more concerning in developing countries, developed

countries still have 12 per 100 000 live births where most of the complications were mostly

preventable. “It’s simple: No woman should die from giving birth.” (United Nations

Foundation, n.d.). The actual issue has a higher and wider impact than what it is believed, since

Maternal mortality is unacceptably high. It was estimated that in 2015, roughly 303 000 women

died during and following pregnancy and childbirth. Almost all of these deaths occurred in

low-resource settings, and most could have been prevented. It not only affects women and

societies, but also somehow highlights the difference between social classes: There are large

disparities between countries, but also within countries, and between women with high and low

income and those women living in rural versus urban areas.

While nearly every region has advanced maternal health, for example, addressing all

causes of maternal mortality, reproductive and maternal morbidities, and related disabilities

over the last two decades with the help of the UN and its different organizations like UNICEF

“it’s clear that girls and women continue to face significant challenges even in countries that

are thought to have the best health care and social services for their people” (WHO, n.d.).

HISTORY OF THE PROBLEM “From 1990 to 2015, the global maternal

mortality ratio declined by 44 per cent – from 385

deaths to 216 deaths per 100,000 live births,

according to UN inter-agency estimates. This

translates into an average annual rate of reduction

of 2.3 per cent. While impressive, this is less than

half the 5.5 percent annual rate needed to achieve

the three-quarters reduction in maternal mortality

targeted for 2015 in Millennium Development Goal

5.” (Unicef, 2017).

Every region has advanced, although levels of maternal mortality remain unacceptably

high in sub-Saharan Africa. As also mentioned, Almost all maternal deaths can be prevented,

as evidenced by the huge disparities found between the wealthiest and needful countries. The

lifetime risk of maternal death in high-income countries is 1 in 3,300, compared to 1 in 41 in

low-income.

“Similar proportion of maternal deaths were caused indirectly by pre-existing medical

conditions aggravated by the pregnancy. Hypertensive disorders of pregnancy, especially

eclampsia, as well as sepsis, embolism and complications of unsafe abortion also claim a

substantial number of lives.” (Unicef, 2017).

Complications require prompt access to quality obstetric services equipped with life-

saving drugs, including antibiotics, and the ability to provide blood transfusions needed to

perform Caesarean sections or other surgical interventions. Health complications and mortality

risk from childbirth has been a tragic but not uncommon event for mothers throughout history.

The chart above shows the decline of maternal mortality in recent centuries. Going back

to the 19th century and looking at countries that have the best health today we see that about

500 to 1,000 mothers died for every 100,000 births. Every 100th to 200th birth led to the

mother´s death.

Since women gave birth much more often than today the death of the mother was a

tragic but not uncommon tragedy. This changed over the last century and today most wealthiest

countries have a maternal mortality ratio below 10 deaths per 100,000 births – the countries

with the lowest maternal mortality reached a level of around 1% of the death rate in the 19th

century.

“The countries that achieved the lowest maternal mortality ratio are Finland, Greece,

Iceland, and Poland. For every 100,000 births, 3 mother´s die” (Rosie Ritchie, 2019). In

addition, the 100-fold decline of maternal mortality is due to the modern scientific

understanding of the cause of maternal mortality and the adoption of practices which appear

surprisingly simple in hindsight. The common reason for the mother to die was puerperal fever

(or childbed fever) which was caused by unhygienic medical staff and medical equipment by

which the mother´s genital tract is infected during childbirth.

CURRENT SITUATION During the United Nations General Assembly 2015, in New York, UN Secretary-

General Ban Ki-moon launched the Global Strategy for Women's, Children's and Adolescents'

Health, 2016-2030. The Strategy is a road map for the post-2015 agenda as described by the

Sustainable Development Goals and seeks to end all preventable deaths of women, children

and adolescents and create an environment in which these groups not only survive, but thrive,

and see their environments, health and wellbeing transformed.

Seeing that it is possible to accelerate the decline, countries have now united behind a

new target to reduce maternal mortality even further. “One target under Sustainable

Development Goal 3 is to reduce the global maternal mortality ratio to less than 70 per 100,

000 births, with no country having a maternal mortality rate of more than twice the global

average.” (UNICEF, 2018)

The maternal mortality rate (MMR) has decreased by almost half within the European

Region between 2000 to 2015, from 33 to 16 deaths per 100 000 live births respectively.

Nevertheless, the highest national maternal mortality rate in the Region is now estimated to be

an appalling 25 times the lowest. Perinatal mortality is defined by WHO as weight specific (≥

1000 g) fetal deaths and early neonatal deaths per 1000 births (live births + stillbirths). “The

perinatal mortality ratio differs significantly between countries, and the ratio is approximately

35 higher in some of the countries in the European Region. However, the perinatal mortality

rate has decreased from 9.5 per 1000 live births in 2000, to fewer than 7.4 in 2013” (WHO,

2014).

Furthermore, in this case, the United States fares worse in preventing pregnancy-related

deaths than most other developed nations. “Despite participation in the Millennium

Development Goals and spending more than any other country on hospital-based maternity

care, the MMR in the U.S. increased from 17 deaths per 100,000 live births in 1990 to 26 deaths

per 100,000 live births in 2015. During the same time period, the global MMR decreased by

44%. The U.S. has also failed to meet prior national goals for maternal mortality reduction and

is not on track to meet the modest Healthy People 2020 goal of reducing maternal mortality by

10% between 2007 and 2020. Although differences in reporting related to a new classification

of maternal deaths in the updated International Classification of Disease can partly explain the

growing number of recorded maternal deaths, improvements in data accuracy are not enough

to account for the alarming rise in MMR” (WHO, 2018).

Needful women in remote areas are the least likely to receive adequate health care. This

is especially true for regions with low numbers of skilled health workers, such as sub-Saharan

Africa and South Asia. “Births in the opulent 20 percent of households were more than twice

as likely to be attended by skilled health personnel as those in the beggarly 20 percent of

households (89 per cent versus 43 per cent)”(UNICEF, 2017). This means that millions of

births are not assisted by a midwife, a doctor or a trained nurse.

Most maternal deaths and disability occur as the result of one or more of three delays:

a delay in recognizing complications; a delay in reaching a medical facility; or a delay in

receiving good quality care. Efforts to address these delays are essential in order to save the

lives of mothers and babies. “Education on family planning and the provision of family

planning services of high quality can also make a difference by making a high impact in

families and concept of education” (UNFPA, 2015).

Furthermore, as mentioned from the Executive Director of UNFPA “More lives could

be saved if women had access to voluntary family planning to ensure that births are spaced

properly, skilled attendance at delivery, and emergency obstetric care. UNFPA is committed

to reducing the high levels of maternal death and disability that exist today” (WHO, 2017).

The death of a mother during pregnancy or childbirth is a human tragedy at the

individual, family and societal levels. The chances of survival not only of the newborn but also

of the other children are substantially diminished when the mother dies. As the focal agencies

within the United Nations system for the health of women and children, WHO, UNICEF and

UNFPA pledge to enhance - both individually and jointly in collaboration with their partners.

their efforts in assisting countries strengthen their maternal health programmes.

But in the 21st century, African American women are once again taking the lead in the

effort to ensure equitable access to care and support for dark-skinned women. In September of

2018, Washington DC Mayor Muriel Bowser convened a Maternal and Infant Health summit

featuring African American female mayors of Flint Michigan, Gary Indiana, Baltimore,

Maryland and Hartford, Connecticut. An audience of nearly 1,500 gleaned information about

the latest research, policies and community health initiatives aimed at supporting better

maternal and reproductive health for black women. (UNICEF, 2017).

In addition, in August of 2018, Dr. Bowser signed an agreement with George

Washington University Hospital that would create a state of the art hospital and trauma center-

-and a full-fledged maternity ward—in Ward 8, one of the poorest, mostly minority areas of

Washington, DC. Construction is slated to begin in 2020, with a goal of opening in 2023.

As they know and Dr. Bowser mentions, big cities mayors recognize this problem and

say they know and are working to solve this issue. “Too often, any maternal death in our

communities is outsized, in terms of the impact it has on families. Mayors are being forced to

extend our reach to do things they used to rely on the federal government to provide. With this

issue, is required to call on the knowledge, the voices and the energy of communities to save

lives. They cannot wait for the next study or report.” (WHO, 2017).

UN ACTIONS The United Nations considers Maternal Mortality one of the biggest and most

important issues which need to be resolved. This is why Maternal Mortality is the fifth of eight

Millennium Development Goals, which meant it was expected to be solved between 1990 and

2015. Countries and leading development institutions joined efforts to meet the needs and reach

the target of the MDG. Also, “Since 1990, the maternal mortality ratio has been cut nearly in half , and most

of the reduction occurred since 2000.” (United Nations, n.d.). “Currently, the ratio of maternal

mortality in developed countries is 1 to 5600 women” (ECOSOC,n.d.) being this a great sign

of improvement and success in the UN programs. The United Nations Population Fund isn't

the only one of the committees taking action in the issue, various committees of the UN have

been also contributing to the solution: “In 2009, Ecosoc held its Annual Ministerial Review on

the theme of global public health. Ministers from 7 countries (Bolivia, China, Jamaica, Japan,

Mali, Sri Lanka, Sudan) delivered “National Voluntary Presentations”, which detailed their

countries’ recent efforts to improve public health (including child health), while offering case

studies on successful initiatives such as health programs with successful health education and

training.” (ECOSOC, n.d.).

Furthermore,” The United Nations Population Fund (UNFPA), the UN Children’s Fund

(UNICEF), the World Health Organization (WHO), and the World Bank, as well as the Joint

UN Programme on HIV/AIDS (UNAIDS), have joined forces with the name Health 4+ (H4+)

to support countries with the highest rates of maternal and newborn mortality.” (ECOSOC,

n.d.). The “Health 4+” help with resources, health plans, health workers and health services.

“In 2010, UN Secretary-General Ban Ki-moon, together with leaders from

governments, foundations, NGOs and business, launched the “Global Strategy for Women’s

and Children’s Health”, a series of simple steps to improve women’s and children’s health ―

measures which, if implemented correctly, could’ve have saved 16 million lives by 2015.”

(ECOSOC, n.d.), and then again in 2016 the UN launched a updated version called “Global

Strategy for women's, children's and adolescents health” (2016-2030), which goal is to ensure

a transformed future for every mother, child and newborn. This strategy, places women,

children and adolescents in the heart of the UN goals.

POSSIBLE SOLUTIONS 1. “Every delivery, including those that take place in the home, should be assisted by a

skilled birth attendant (a midwife, physician, or nurse) who has been trained to

proficiency in basic techniques for a clean and safe delivery, and recognition and

management of prolonged labor, infection, and hemorrhage” (UNICEF, 2017).

2. Essential obstetric care should be accessible to address complications of childbirth that

cannot be managed by a skilled birth attendant. This requires a network of good-quality

essential care facilities that provide basic essential obstetric care: administration of

antibiotic, oxytocic, and anticonvulsant drugs; manual removal of the placenta; removal

of retained products of conception; and assisted vaginal delivery.

3. Postpartum care (Care from delivery until the sixth completed week after delivery,

including care both at home in the formal health care system), is critical during the first

hours after birth and important throughout the first month. For the mother, such care

should emphasize the prevention, timely recognition, and treatment of infection;

postpartum hemorrhage; and complications of hypertensive disease of pregnancy.

4. The following strategies are recommended for incorporation into preconceptional and

antenatal care:

- Greater access for women and men of reproductive age to family planning

services that provide effective contraception along with counseling on the risks

for adverse birth outcomes.

- Early detect and timely treatment of hypertensive disease of pregnancy.

- Intermittent preventive and early treatment of malaria, especially for

primiparae.

5. Educating women is a human rights priority regardless of the manifold economic and

social benefits it affords a society, but it could also significantly reduce maternal mortality

rates.

6. Increase the investigation in areas such as AIDS, TB, malaria and child health to prevent

and lower the number of deaths due to these. Better the communication between researchers

and policymakers so new discoverments can reach every single person that needs it no matter

where they are.

References: In World Health Organization. (2018). Maternal mortality. Retrieved from

https://www.who.int/news-room/fact-sheets/detail/maternal-mortality

UNFPA. (2018). In United Nations Population Fund. Retrieved from

https://www.unfpa.org/about-us

WHO Maternal mortality ratio (per 100 000 live births). (n.d.). In World Health

Organization. Retrieved from

https://www.who.int/healthinfo/statistics/indmaternalmortality/en/

WHO 7 Facts about Maternal Health you Should Know. (2018). In United Nations

Foundation. Retrieved from https://unfoundation.org/blog/post/7-facts-about-

maternal-health-you-should

know/?gclid=CjwKCAjw0ZfoBRB4EiwASUMdYfa6IZpzYKFHrVxLiimGx1Q9-

kqdQF7W_1J_kj9YkyLDdtO-wYadphoC7LwQAvD_BwE

Maternal mortality. (2017). In Unicef. Retrieved from https://data.unicef.org/topic/maternal-health/maternal-mortality/

Maternal Mortality. (2019). In Our World in Data. Retrieved from https://ourworldindata.org/maternal-mortality

Global Strategy for Women's, children's and Adolescents Health. (2019). In World Health

Organization. Retrieved from https://www.who.int/life-course/partners/global-

strategy/en/

Improve Maternal Health: MDG 5. (n.d.). In ECOSOC. Retrieved from

https://www.un.org/en/ecosoc/about/mdg5.shtml

WHO, UNICEF, UNFPA and The World Bank, Trends in Maternal Mortality: 1990 to 2015, WHO, Geneva, 2015.

WHO and UNICEF, The Sisterhood Method for Estimating Maternal Mortality: Guidance notes for potential users, WHO, Geneva 1997.

AbouZahr C, Royston E. 1991. Maternal Mortality: A Global Factbook . Geneva: WHO.

AbouZahr C, Wardlaw T, Stanton C, Hill K. 1996. Maternal mortality. World Health Statistics

World Health Organization (WHO). 2001. Maternal mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA. Geneva: WHO.

World Health Organization (WHO). 2002. a. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva: WHO.