by Caitlin Nichols
Worldwide, approximately 289,000 women die every year due to pregnancy- and childbirth-related complications, with 99% of these deaths occurring in developing nations. What can be done to address this pressing world health issue? Thankfully, many maternal deaths are preventable through accurate information and proper medical care, and organizations such as the World Bank are working to increase access to these vital resources. Before we can discuss solutions to the maternal mortality problem, however, we must first understand its causes.
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On April 23, 2015, the World Bank announced that it would give $500 million to fund the Saving One Million Lives (SOML) initiative, a program designed to improve the health of mothers and children in Nigeria . This sum, to be dispersed over 4 years, exceeds the World Bank’s donation to successfully combat the spread of the Ebola virus in West Africa by $100 million , underscoring the importance of improving maternal and child health. The focus is well deserved: while Nigeria is home to Africa’s largest economy, it also ranks among the nations with the most maternal deaths per year, second only to India . On average, over 100 Nigerian women die every day—or 40,000 every year—due to pregnancy- and childbirth-related complications. This means that 1 in every 13 Nigerian women will eventually perish as a direct result of a pregnancy . Sadly, this problem of maternal deaths is not exclusive to any one continent or nation: approximately 289,000 women worldwide suffer a similar fate annually, with 99% of these pregnancy-related deaths occurring in developing nations .
What can be done to address this pressing world health issue? Thankfully, many maternal deaths are preventable through accurate information and proper medical care, and organizations such as the World Bank are working to increase access to these vital resources. Before we can discuss solutions to the maternal mortality problem, we must first understand its causes.
The Biology of Pregnancy
Pregnancy is a unique state in the lifecycle of both the mother and the developing embryo. After egg and sperm unite in the oviduct, the resulting embryo begins to divide. On the fifth or sixth day after fertilization, the embryo implants in the lining of the mother’s uterus. At this point, specialized cells in the embryo begin to form the placenta. This organ connects the developing fetus to the mother and allows for exchange of nutrients, gasses, and wastes. While no mixing of maternal and fetal blood occurs in the placenta, maternal blood vessels underlying this organ are more dilated than normal to provide adequate oxygen and nutrient supplies to the fetus. The umbilical cord attaches the developing fetus to the placenta. During delivery, first the baby is delivered through the birth canal, followed by the placenta .
Figure 1: Biology of pregnancy. During pregnancy, the developing embryo receives nutrients through the umbilical cord. Although there is no mixing of maternal and fetal blood, there is exchange of nutrients and waste across blood vessels in the placenta. This specialized system of blood vessels is important for the survival of the embryo, but also leads to the potential for substantial bleeding during childbirth. Image from .
Causes of Maternal Mortality
Unfortunately, the complexities of human pregnancy and birth make it a risky endeavor. One of the most prevalent causes of maternal death is severe bleeding after delivery, also known as post-partum hemorrhage (PPH). PPH accounts for approximately 27% of maternal deaths worldwide, or more than 75,000 deaths annually. As holds true for pregnancy-related deaths as a whole, more than 99% of women who die from PPH reside in developing nations .
PPH is defined as losing more than 500 milliliters of blood (about 10% of a person’s total blood volume) within 24 hours of giving birth. Causes of PPH include anemia, damage to the birth canal, failure of the uterus to contract properly after delivery, and failure to deliver a portion of the placenta, preventing the associated maternal blood vessels in the uterus from restricting to their normal size .
Tragically, many deaths caused by PPH are preventable through proper medical care before, during and after the birth. For example, anemia can be prevented by routinely providing all pregnant women with iron and folate dietary supplements. In addition, the World Health Organization has established recommended practices during delivery to help prevent PPH. This set of treatments, known as the active management of the third stage of labor (AMTSL), includes injecting a hormone called oxytocin after the baby has been delivered. This hormone stimulates the uterus to contract, helping to close blood vessels and preventing excessive bleeding. Studies have shown that implementation of AMTSL reduces occurrence of PPH by 62%. However, without adequate education about proper medical care or access to skilled attendants during birth, many women in developing nations do not follow these practices, increasing their risk for PPH .
Figure 2: What are pregnant women dying from? Without proper medical care, complications during pregnancy can have serious—and perhaps deadly—results. Image reused with permission (www.who.int).
The second most common cause of maternal death after severe bleeding is pregnancy-induced high blood pressure (hypertension). Pregnancy-related hypertension accounts for about 14% of maternal deaths, or about 40,000 women annually. As with PPH, more than 99% of these deaths occur in developing nations .
One particularly dangerous type of hypertension for both the mother and fetus is that caused by preeclampsia, a disorder characterized by high blood pressure after week 20 of pregnancy and high levels of protein in the urine (as a result of kidney problems). If severe enough, the high blood pressure caused by preeclampsia can permanently damage a mother’s organs, including the brain and liver, and can lead to seizures (a condition known as eclampsia) and death. Preeclampsia can also impair the function of the placenta, leading to underweight or premature babies. Preeclampsia causes additional premature births because, unfortunately, delivery of the fetus is the only “cure” for the condition; thus, in severe cases, doctors can be forced to deliver a fetus dangerously early in an attempt to save the lives of both the mother and the fetus .
While preeclampsia is difficult to diagnose and its causes are poorly understood, adequate medical care can help lessen its dangers. For example, prenatal screening can detect high blood pressure early in pregnancy so the mother’s condition can be monitored and she can avoid activities that further raise her blood pressure. In addition, a drug called magnesium sulfate can prevent development of seizures in women with preeclampsia and decrease their risk of death by more than 50% . Unfortunately, use of magnesium sulfate is not widespread in developing countries due to lack of information, inadequate training of healthcare workers, and limited availability of the drug .
Global Health Implications
As mentioned previously, the vast majority of maternal deaths due to causes such as PPH and preeclampsia occur in developing countries. Of the 800 women that die every day of pregnancy-related complications, 500 live in sub-Saharan Africa and 190 live in Southern Asia, while only 6 live in high-income countries . To put these numbers in perspective, while Nigeria accounts for less than 3% of worldwide pregnancies every year, its maternal deaths compose nearly 14% of the worldwide annual total .
Figure 3: Where does maternal death happen? Sub-Saharan Africa, particularly Nigeria, has the highest risk of dying during pregnancy in the world. The number of deaths has decreased in the past twenty-five years, but there is still much that can be done to improve maternal health in the region. Image reused with permission (www.who.int).
In order to address such disparities, the United Nations included improving maternal health as one of its eight Millennium Development Goals (MGDs) in the year 2000. MGD5 aims to decrease maternal deaths by 75% between 1990 and 2015 through efforts such as researching underlying causes of high maternal death rates and working with local governments to increase healthcare access for pregnant women .
Much progress has been made towards reaching MGD5. For instance, worldwide maternal mortality has fallen by 45% since 1990, with some sub-Saharan nations decreasing maternal deaths by more than half. Despite this progress, MGD5 was not achieved by the start of this year, and much work remains to be done .
One of the greatest remaining disparities is in access to skilled healthcare during and after pregnancy and delivery. Many complications of pregnancy and labor that lead to maternal mortality could be avoided or treated with the help of a trained health provider, such as a midwife, nurse, or doctor. However, only about a third of women in low-income countries obtain the recommended four pre-birth health checkups, and only 46% of women give birth with a skilled attendant present. Along with a lack of trained healthcare workers and proper equipment, poor women in rural areas also face the barriers of distance, expense, lack of education, and cultural practices that prevent them from seeking proper care during and after their pregnancies .
What Can Be Done?
Despite the complex sociocultural and economic factors that contribute to maternal mortality in the developing world, some promising solutions exist. One example of a potentially effective model is the World Bank’s involvement in the SOML initiative in Nigeria. This project uses a funding instrument known as Program-for-Results, under which support is distributed to local and state governments only upon achievement of clearly defined and measurable goals. Such goals under the SOML include increased rates of skilled birth attendance and improved quality of care at local health centers. Progress towards these and other goals will be monitored by the World Bank to determine if the poorest 40% of the population are receiving the intended benefits of the initiative. This program, with its emphasis on measurable results, increased accountability, and improved management, could provide a useful model for other maternal health programs worldwide .
Caitlin Nichols is a PhD candidate in the Harvard Biological and Biomedical Sciences program.
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 Illustration from Anatomy & Physiology, OpenStax CNX. http://cnx.org/contents/1704097d-1012-4798-8ef6-1598d73e7b15@3/Embryonic_Development#fig-ch29_02_08, May 31, 2015. CC BY 3.0 OpenStax College.