World Population Day 2004 - Introduction

Maternal Deaths Still Unacceptably High

Recent findings on maternal mortality by WHO, UNICEF and UNFPA show that a woman living in sub-Saharan Africa has a 1 in 16 chance of dying in pregnancy or childbirth. This compares with a 1 in 2,800 risk for a woman from a developed region. These findings, as well as statistical data by region and country, are contained in a new global report on maternal mortality released in October 2003 by the three agencies.

Of the estimated 529,000 maternal deaths in 2000, 95 per cent occurred in Africa and Asia, while only 4 per cent (22,000) occurred in Latin America and the Caribbean, and less than one per cent (2,500) in the more developed regions of the world.

Experience from successful maternal health programmes shows that much of this death and suffering could be avoided if all women had the assistance of a skilled health worker during pregnancy and delivery, and access to emergency medical care when complications arise.


A. Providing Emergency Obstetric Care to All in Need
This does not mean that all births should take place in well-equipped health facilities. It does mean that all pregnant women should have access to functioning facilities that offer essential obstetric care if they develop complications.

This, in turn, has other implications for a country's health care system. Since complications can not be prevented or reliably predicted, it requires that facilities capable of delivering essential obstetric care are distributed throughout the country, that they are well-equipped and staffed 24 hours a day, seven days a week — and that the women who need them have a way of getting to them in time to prevent death or disability.


Setting Standards for Obstetric Care
Basic emergency obstetric care, provided in health centres and small maternity homes, includes the capabilities for:

• Administration of antibiotics, oxytocics, or anticonvulsants

• Manual removal of the placenta

• Removal of retained products following miscarriage or abortion

• Assisted vaginal delivery with forceps or vacuum extractor.

• Comprehensive emergency obstetric care, typically delivered in district hospitals includes all basic functions above, plus Caesarean section and safe blood transfusion.

In guidelines jointly issued in 1997 by WHO, UNICEF, and UNFPA, it is recommended that for every 500,000 people there should be four facilities offering basic and one facility offering comprehensive essential obstetric care.

To manage obstetric complications — the life-saving component of maternity care — a facility must have trained staff and a functional operating theatre, and must be able to administer blood transfusions and anaesthesia.

Existing facilities (district hospitals and health centres) can often, with just a few changes, become capable of providing emergency obstetric care.

Reducing Life-Threatening Delays
Timing proves to be critical in preventing maternal death and disability: Although post-partum haemorrhage can kill a woman in under two hours, for most other complications, a woman has 12 hours or more to get life-saving emergency care. The “three delays” model (see below) has proved to be a useful tool to identify the points at which delays can occur in the management of obstetric complications, and to design programmes to address these delays.

The first two "delays" (delay in deciding to seek care and delay in reaching appropriate care) relate directly to the issue of access to care, encompassing factors in the family and the community, including transportation. The third "delay" (delay in receiving care at health facilities) relates to factors in the health facility. Unless the three delays are addressed, no safe motherhood programme can succeed.

Because they require that many sequential procedures all function — from ante-natal care and preparation to attended births with referral capabilities — maternal mortality reduction activities are an integral part of the health sector reform effort and of the sector-wide approaches. They also provide an indication of the success of such approaches.



B. Ensuring Skilled Attendance at Births
Every minute, 110 women experience a complication in their pregnancy

The single most critical intervention for safe motherhood is to ensure that a health worker with midwifery skills is present at every birth, and transportation is available to a more comprehensive level of obstetric care in case of an emergency. Up to 15 per cent of all births are complicated by a potentially fatal condition, and women attended by trained attendants are more likely to receive treatment early, when the situation can still be controlled.

Yet in the developing world today, only 58 per cent of all deliveries take place with the assistance of a trained attendant.

Experience shows, however, that the training of birth attendants needs to be part of a broader strategy, including functioning referral systems and back-up professional support. Skilled attendants alone cannot effectively reduce maternal mortality – they need to be linked up with a larger health care system with the facilities, supplies, transport and professionals to provide emergency obstetric care when it is needed. Skilled attendance is one key indicator used in measuring progress in reducing maternal mortality.

A Focus on Professional Care

In addition, a paradigm shift is taking place in the arena of attendance at birth. The focus has shifted from training of traditional birth attendants (who are not professionals by definition) to making professional care accessible. Traditional birth attendants simply do not have the lifesaving skills to deal with life-threatening problems such as haemorrhage, eclampsia or obstructed labour, which together account for the majority of maternal deaths.

The necessities include:

• A special focus on emergency obstetric care

• Treatment protocols, facility upgrading

• Record-keeping and monitoring

• Prenatal and post-natal counselling

• Delivery care norms and procedures

• Use of postpartum family planning services

• Establishment of a referral system for obstetric complications
  The Limitations of Screening

Some women may clearly be at risk for complications. But often complications arise with little or no warning. Since it is almost impossible to predict who will develop a life-threatening complication, all pregnant women should have access to a qualified health provider, for prenatal and delivery care, and adequate services should be available at referral level.

In some cases, emergency obstetric surgery, such as Caesarean sections and manual removal of retained placenta, could effectively be delegated to specially trained nurses, if adequate facilities were available. However, this is occurring in very few places.

The Value of Prenatal Care
Although the previous emphasis on prenatal care and training of birth attendants did not succeed in reducing maternal deaths, prenatal care can be a valuable way to establish a relationship between women and the health system. Trained birth attendants can also help foster a dialogue with female community leaders about the needs of pregnant women, and ways of mobilizing support for them.

WHO and UNICEF recommend that all pregnant women have two to four prenatal visits, focusing on preparing for the birth by identifying an attendant, the nearest emergency obstetric care and available transport. Prenatal care should also include:

• Immunization against tetanus

• Iron and folate tablets, as well as multiple micronutrient supplementation, and, when available, malaria prophylaxis

• Hookworm treatment

• Diagnosis and management of sexually transmitted and urinary tract infections early detection and management of complications such as pre-eclampsia

General health problems that can also be identified through prenatal care. Infection with HIV is a rapidly growing threat to women's health, and HIV/AIDS is an increasingly common cause of maternal death in many countries. Malaria contributes in several different ways to poor maternal and neonatal health. In some countries hypertension, heart disease, and kidney disease are relatively common and all contribute to maternal deaths. Where female genital cutting is practiced the resultant scarring often leads to problems during labour and delivery.


C. Reducing Risks by Offering Contraceptive Services
Every minute, 190 women face an unwanted or unplanned pregnancy.

Clearly, a woman’s ability to plan how many children she wants and when she wants them is central to the quality of her life. In places where emergency obstetric care is not available, however, access to contraception may literally be a matter of life or death. Each pregnancy multiplies a woman’s chance of dying from complications of pregnancy or childbirth.

Meeting the existing demand for family planning services would reduce pregnancies in developing countries by 20 per cent and maternal deaths and injuries by a similar degree or more.

About 13 per cent of maternal deaths are attributed to unsafe abortions, coupled with lack of skilled follow-up. The high level of unmet need for quality contraceptive services and the corresponding number of unwanted pregnancies — is a key reason why so many seek out abortions.

More than one quarter of pregnancies worldwide, about 52 million annually, end in abortion. This is the proportion in Latin America, where abortion is generally illegal, as well as in the United States and China, where the procedure is legally available.

In South and Southeast Asia, about one in five pregnancies ends in abortion, while in Sub-Saharan Africa and North Africa and the Middle East, the proportion of pregnancies terminated by abortion appears to be about one in ten.

Reducing Unwanted Pregnancies
Expanding access to client-centred family planning information and services, where a range of effective contraceptive methods is offered and responsive counselling provided, reduces the number of unplanned pregnancies, which often lead to sub-optimal pregnancy care and unsafe abortion procedures. Currently as many as 50 per cent of pregnancies are unplanned, and 25 per cent are unwanted.

At the same time, strengthening maternal health services can also bring benefits to the overall health system and enhance the impact of a country's broader reproductive health program.

Contraceptive Use Rises, But Unmet Needs Remain
The use of modern contraceptive methods, including voluntary sterilization, has increased rapidly over the past 30 years, especially in countries with strong family planning programmes. Almost all of the increase reflects greater use by women rather than their partners. Fewer than 5 per cent of couples in the majority of developing countries rely on male methods (the condom, withdrawal or vasectomy).

Still, an estimated 228 million women who want to delay or cease childbearing—roughly one in six women of reproductive age—are in need of effective contraceptive methods.

Substantial proportions of women in every country—more than 50 per cent in some—say their last birth was unwanted or mistimed.

More than 50 million of the 190 million pregnancies worldwide each year end in abortions; many of these procedures are clandestine, performed under unsafe conditions.

Limited Contraceptive Options
Differing patterns of contraceptive use may not reflect women’s personal preferences as much as political and economic decisions made by governments to emphasize certain methods, the attitudes of medical professionals, cost, the limited range of methods offered in some countries or an uneven availability of contraceptive supplies.

In fact, high quality family planning services are often not available: One evaluation of family planning programmes in 88 developing countries concludes that family planning services are routinely made available to women at reasonable cost in only 14 countries.

In many developing countries, at least a third of women need contraceptive services. However,

• some women do not know about modern methods, are unable to obtain or afford them, or distrust or dislike the methods that are available,

• single women and teenagers may be barred from obtaining contraceptive services

• other women are ambivalent about whether they want a child or are unsure about their ability to become pregnant

• still others live with a partner who does not approve of contraception or who wants them to become pregnant.