Maternal Mortality

Overview


Maternal mortality is defined as the death of a woman during pregnancy or 42 days of delivery or termination of the pregnancy, regardless of the duration and location of the pregnancy, from any cause related to or exacerbated by the pregnancy or its management [1] . The maternal mortality ratio (MMR) is measured by the number of maternal deaths per 100,000 live births. Maternal mortality is often used as a proxy measure for the quality of a country’s health care system, a measure of development, and an indicator of economic and gender equality and health equity [2] [3]



Health Impact


The United Nations’ Millennium Development Goals (MDG) officially established the need to improve maternal health and decrease maternal mortality worldwide as a global priority for achieving a healthier and more equitable global community. According to MDG 5, countries are committed to reducing 1990 maternal mortality ratios by 75 percent by the year 2015. The magnitude of this goal varies by country as the rates of maternal death differ widely across the world [4]

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Overall, maternal death is on the decline, and globally, it has decreased 34 percent from an estimated 546,000 maternal deaths annually in 1990 to 358,000 in 2008. However, approximately 1,000 women continue to die each day from preventable pregnancy and childbirth related causes [5] . The primary causes of maternal death include: hemorrhaging, infection, high blood pressure during pregnancy (eclampsia and pre-eclampsia), obstructed labor, and unsafe abortion [6] . These complications leading to the majority of maternal deaths are preventable and/or treatable with prompt and adequate medical attention.

Unfortunately, 99 percent of maternal mortalities occur in the developing world, where less than half of births take place with the assistance of a skilled attendant [7] . In 2008, an estimated half of all maternal deaths occurred in only six countries: India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of Congo [8] , and a comparison of the aggregate MMR between industrialized countries, 14 per 100,000 live births, and the world’s least developed countries, 590 per 100,000, reveals a wide disparity [9] . As will be discussed further below, these disparities can be attributed to political, social, and economic forces that disproportionately structure risk and constrain maternal agency, particularly in regards to accessing and obtaining necessary emergency obstetric care.

Medical Anthropology Research and Applied Work


Although biomedicine has identified a number of biological causes of maternal death, medical anthropology and applied research have revealed a variety of distal causes, including political, social, and economic factors that impact maternal health and survival particularly as a result of difficulty in accessing the appropriate resources. Moreover, because prenatal care and the assistance of a skilled birth attendant during delivery have been shown to reduce maternal deaths, the maternal mortality ratio of a country functions as an indicator of the availability, accessibility, acceptability, and actual utilization of health resource and facilities [10] [11] [12] . Thus, although the contexts of maternal deaths vary across the globe, social exclusion, gender inequality, and poverty are all familiar challenges in the lives of the women most at risk. These various forms of institutionalized discrimination coalesce in the lives realities of women and constrain maternal agency and decision-making.

Much of the medical anthropological literature on maternal mortality has approached the issue from this political economic perspective, thus highlighting the health consequences of social inequality [13] [14] . For example, in Peru, the overall maternal mortality ratio for the country is 240 per 100,000 live births [15] . However, a more nuanced examination of the distribution of maternal mortality within the country reveals a huge incongruence between urban and rural rates of maternal death. In the capital city of Lima, the maternal mortality rate is 52 per 100,000, while in Puno, a rural, southeastern, highland province, that rate jumps to an overwhelming 361 [16] . Relevant literature has identified several major care-related delays contributing to the high rates of maternal mortality in the country. These include delays in the decision to seek care, in arriving at care facilities, and in receiving appropriate care at these facilities. These delays are inextricably tied to a lack of availability, accessibility, and acceptability of care and the presence of persistent ethnic and gender discrimination [17] [18] [19] [20] .



A recent response to these challenges in Peru has been the development of mamawasis (maternal waiting houses) that have been created for women to stay in during the last few weeks leading up to their due date. Mamawasis are located near health clinics and hospitals, allowing for easier physical access to care, and they also allow for family members to stay with the woman, provide culturally appropriate foods, and observe some traditional birthing practices, such as delivering in an upright position [21] [22] . This integration of traditional and biomedical approaches to birth has been well received in the south of the country, where the mamawasis are largely concentrated, and has served to reduce maternal mortality [23] .

Another avenue of response to the high rates of maternal death worldwide has been the increased reliance on community health workers and midwives to provide prenatal care at home, on-going monitoring, and referrals for high-risk pregnancies, particularly in rural areas. In Vietnam, ethnic highland women experience struggles similar to those discussed above when seeking care during pregnancy and delivery [24] . In fact, in some rural areas, the maternal mortality ratio is ten times higher than the national average. One major factor playing into this striking disparity is the difficulty in physically accessing care, particularly in outlying, mountainous areas. Another major issue is a lack of trust between state institutions and the Hmong [25] . Thus, among the Hmong in rural Vietnam, an 18-month midwife training program for local women has been developed in order to provide maternal health care in the home, when possible [26] . As a result, the country has seen an increase in the number of births assisted by skilled attendants as well as the number of birth occurring in health facilities.



Online Resources


WHO Maternal Health: http://www.who.int/maternal_child_adolescent/topics/maternal/en/index.html
Maternal Mortality Portal: http://maternalmortalityportal.org/
Every Mother Counts: http://www.everymothercounts.org/
The Safe Motherhood Initiative: http://www.safemotherhood.org/

Further Reading


Campbell, Oona M. R., and Wendy J. Graham
2006 Strategies for Reducing Maternal Mortality: Getting On With What Works. The Lancet 368(9543):1284-1299

Diaz-Granados, Natalia, et al.
2011 Monitoring Gender Equity in Health Using Gender-Sensitive Indicators: A Cross-National Study. Journal of Women's Health 20(1):145-153.

Hogan, Margaret C., et al.
2010 Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet 375(9726):1609-1623.

Paxton, A. and Wardlaw, Tessa
2011 Are We Making Progress in Maternal Mortality? The New England Journal of Medicine 364(21):1990.

United Nations Children's Fund
2008 The State of the World's Children 2009: Maternal and Newborn Health. UNICEF.

Yamin, Alicia Ely
2007 Deadly Delays: Maternal Mortality in Peru. A Rights-Based Approach to Safe Motherhood. 0968-8080.


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References



  1. ^ The World Health Organization (2011) WHO: Millennium Development Goal 5. WHO, ed.
  2. ^ The World Health Organization (2011) WHO: Millennium Development Goal 5. WHO, ed.
  3. ^ Diaz-Granados, Natalia, et al. (2011) Monitoring Gender Equity in Health Using Gender-Sensitive Indicators: A Cross-National Study. Journal of Women's Health 20(1):145-153.
    World Health Organization
  4. ^ World Health Organization (2012) WHO: Maternal Mortality, http://www.who.int/mediacentre/factsheets/fs348/en/index.html
  5. ^ UNICEF (2010) Maternal deaths worldwide drop by third, http://www.unicef.org/media/media_56006.html
  6. ^ World Health Organization (2012) WHO: Maternal Mortality, http://www.who.int/mediacentre/factsheets/fs348/en/index.html
  7. ^ United Nations Children's Fund (2008) The State of the World's Children 2009: Maternal and Newborn Health. UNICEF.
  8. ^ Hogan, Margaret C., et al. (2010)Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet 375(9726):1609-1623.
  9. ^ Paxton, A. and Wardlaw, Tessa (2011) Are We Making Progress in Maternal Mortality? The New England journal of medicine 364(21):1990.
  10. ^ Campbell, Oona M. R., and Wendy J. Graham (2006) Strategies for Reducing Maternal Mortality: Getting On With What Works. The Lancet 368(9543):1284-1299
  11. ^ The World Health Organization (2011) WHO: Millennium Development Goal 5. WHO, ed.
  12. ^ Yamin, Alicia Ely (2007) Deadly Delays: Maternal Mortality in Peru. A Rights-Based Approach to Safe Motherhood. 0968-8080.
  13. ^ Carey, James (1990) Social System Effects on Local Level Morbidity and Adaptation in the Rural Peruvian Andes. Medical Anthropology Quarterly n.s.(4):266-295.
  14. ^ Singer, Merrill (1995) Beyond the Ivory Tower: Critical Praxis in Medical Anthropology. Medical Anthropology Quarterly 9(1):80-106.
  15. ^ United Nations Children's Fund (2008) The State of the World's Children 2009: Maternal and Newborn Health. UNICEF
  16. ^ United Nations Population Fund Peru (2009) UNFPA - Peru: Informacion Sociodemographics.
  17. ^ Bristol, Nellie (2009) Dying To Give Birth: Fighting Maternal Mortality In Peru. Health Affairs 28(4):997-1002.
  18. ^ Campbell, Oona M. R., and Wendy J. Graham (2006) Strategies for Reducing Maternal Mortality: Getting On With What Works. The Lancet 368(9543):1284-1299
  19. ^ Fraser, Barbara (2008) Peru makes progress on maternal health. The Lancet 371(9620):1233-1234.
  20. ^ Yamin, Alicia Ely (2007) Deadly Delays: Maternal Mortality in Peru. A Rights-Based Approach to Safe Motherhood. 0968-8080.
  21. ^ Fraser, Barbara (2008) Peru makes progress on maternal health. The Lancet 371(9620):1233-1234.
  22. ^ Callister, Lynn C. (2009) Mamawasi: Culturally Sensitive Birthing for Peruvian Women. Global Health and Nursing 34(1):66.
  23. ^ Fraser, Barbara (2008) Peru makes progress on maternal health. The Lancet 371(9620):1233-1234.
  24. ^ Ahlmark, Nick and Nicole Precel (2011) Vietnam: Between Tradition and Modernity, http://www.aljazeera.com/photo_galleries/programmes/201012148387545806.html
  25. ^ Ahlmark, Nick and Nicole Precel (2011) Vietnam: Between Tradition and Modernity, http://www.aljazeera.com/photo_galleries/programmes/201012148387545806.html
  26. ^ Aljazeera (2011) Birthrights: Mountain Midwives of Vietman, http://www.aljazeera.com/programmes/birthrights/2011/04/201142663927915842.html