India accounted for a third of all maternal deaths in 2015: report

One-third of the total maternal deaths in 2015 happened in India, where 45,000 mothers died during pregnancy or childbirth while Nigeria reported the maximum maternal death of 58,000, says a report in the journal Lancet.

The latest Lancet series on maternal health reveals that the past quarter century has delivered progress for some women and their newborn babies. Maternal deaths globally have fallen by nearly half (44 per cent) since 1990, and use of maternity services has increased markedly.

At the same time, nearly one quarter of babies worldwide are still delivered in the absence of a skilled birth attendant and the Millennium Development Goal (MDG) for maternal health fell far short of achievement, says the report.

Some countries and groups of women saw little or no progress, despite significant global political attention on maternal health. In sub-Saharan Africa, a woman's lifetime risk of dying in pregnancy or childbirth remains an appalling 1 in 36 compared with 1 in 4,900 in high income countries.

The Lancet Maternal Health Series shows light on the causes, trends, and prospects for maternal health in the current era of rapid demographic, epidemiological, and socioeconomic transition. It analyses experiences of the past 25 years, and exposes the growing threat to progress caused by poor quality care and inequity of access.

Since 1990, the gap between the group of countries with the highest level of maternal mortality and the group with the lowest has doubled in size, says the report.

''With 210 million women becoming pregnant and the delivery of 140 million newborn babies each year, it is urgent to improve the quality of care and reduce disparities in access, so securing future economic and social development and supporting the vision of the 2030 Sustainable Development Goals (SDGs) and the Global Strategy for Women's, Children's, and Adolescents' Health.''

The report cites a growing risk of over-medicalisation of normal pregnancy and birth, with the routine use of interventions unsupported by evidence in high- and middle-income countries, and in betteroff groups in low-income countries.

Facility-based births continue to rise, but maternity care that is too much, too soon may cause harm, raise health costs, and contribute to a culture of disrespect and abuse.

At the same time, poor quality care that is too little, too late jeopardises the health of women and their newborn babies, whether in sparsely-populated rural areas, dense urban centres, or in settings marked by environmental or political fragility. Furthermore, despite the increases in maternity care coverage in the past 25 years, an estimated quarter of pregnant women still do not access skilled care at birth.

Opportunities for future progress in improving quality of care and reducing inequities lie not only in wider adoption of effective maternal health interventions and models of care, but also in broader developments. These include the increasing fiscal space for health investments in low- and middle-income countries, urbanisation, Universal Health Coverage, and promising new approaches for expanding the reach and effectiveness of care through behavioural economics, mHealth, and the data revolution.

There are also challenges on the horizon that can impede or reverse progress, including a diluted focus on maternal health, weak global and national governance, and natural and human-made crises, such as climate change, disease outbreaks, conflict, and mass migration.

The Series concludes with a five-point agenda for change: good quality care for every woman, every newborn, everywhere; equity through Universal Health Coverage; health system resilience, strength and responsiveness; sustainable financing for maternal and newborn health; and better evidence, advocacy, and accountability for progress.

At a glance:

• In 2015, 216 women died of maternal causes per 100 000 live births - down 44 per cent from 385 per 100 000 in 1990 - but still far short of the MDG 5a target of a 75 per cent reduction. The global target for 2030 is 70 per 100 000, requiring a 68 per cent reduction;
• In 1990, the pooled maternal mortality ratio for the 10 countries with the highest levels was 100 times greater than the pooled maternal mortality ratio for the 10 countries with the lowest levels, but by 2013, the gap had doubled to 200 times greater;
• The significant burden of maternal morbidity has become more apparent, with an estimated 27 million episodes from the five main direct obstetric causes alone in 2015;
• Three-quarters of women now deliver with assistance from a skilled birth attendant and two-thirds receive at least four antenatal care visits. Nearly 53 million women, concentrated in the poorest countries or among the poorest women within countries, receive no skilled assistance at birth;
• There are 51 high quality evidence-based guidelines available for maternity care services, developed by both government and non-governmental organisations from a variety of countries, but none developed by low-income countries. Within these guidelines there are 78 single interventions or groups of interventions recommended for use, and 37 recommended against use;
• In seven sub-Saharan African countries studied, five had more than a quarter of their facility births in sites without capability to provide care for uncomplicated childbirth. In four countries, more than two-thirds of facility births were in sites that lacked three elements of basic infrastructure, such as water, and more than half of facility births were in sites unable to provide basic emergency obstetric care;
• Modelled estimates point to the need for more than 18 million additional health workers by 2030 to meet the SDGs targets. Sub-Saharan African countries with the largest numbers of births (eg. Democratic Republic of Congo, Tanzania, Kenya, and Ethiopia) have some of the lowest densities of midwives and obstetricians (<2 per 1 000 pregnancies);
• A review of 14 high-income countries showed average costs for vaginal births in the US were more than seven times higher than in Norway, and more than four times higher for caesarean sections. Costs for medical liability were high, but half of these 14 countries had no-fault systems to mitigate such costs, and three had partial systems.

As more women survive childbirth, the global burden of poor maternal health is shifting markedly from avoidable deaths to an increasingly diverse array of maternal morbidities. Four major transitions have contributed to increasing diversity and divergence in the burden of poor maternal health across the world.

Demographic: Despite falling birth and death rates, the young age structure of the global population and the high unmet need for contraception continue to drive population growth, placing particular stress on fragile health systems.

Epidemiological: Low- and middle-income countries are following patterns in high-income countries, with increasing incidence of diabetes, heart disease, hypertension, and other chronic conditions. As direct causes of maternal mortality decline, indirect causes of maternal mortality and morbidity are becoming more prominent, including those related to mental health.

Socioeconomic: As individuals and communities become more prosperous, many lifestyle and behavioural changes occur. This includes older ages of women at first birth; increased obesity and noncommunicable diseases; and greater aspiration to use formal-sector health services and technologies, and receive woman-centred care.

Environmental: The impact of climate change, environmental degradation, and natural disasters on human health are population-wide, but it is often women who are most affected by these shifts and shocks. For example, women may need to spend more time collecting fuel and water and so have less time to seek care for themselves and their children. Women also face additional risks in pregnancy from vector-borne or hygiene-related infections, such as malaria, Zika, cholera or Ebola.

For women using services, some receive excellent care but too many experience one of two extremes: too little, too late, where women receive care that is not timely or sufficient, and too much, too soon, marked by over-medicalisation and excessive use of unnecessary interventions. Both extremes represent maternal health care that is not grounded in evidence. And other women receive no care at all.

A growing number of low- and middle-income countries now straddle the two extremes of maternal health care, with too little, too late care among the most vulnerable, and too much, too soon care among the wealthy and those in private care. Indeed, access to evidence-based care remains inadequate across all settings.

It is no longer acceptable to merely encourage women to give birth in health facilities, many of which continue to lack emergency obstetric care, reliable water supply, and even the most basic capability to manage uncomplicated deliveries and provide respectful evidence-based routine care.