Improving Global Maternal

Chapter 58

Health: Challenges
and Opportunities
GWYNETH LEWIS, LESLEY REGAN, CHELSEA MORRONI,
and ERIC R.M. JAUNIAUX

Maternal and Reproductive Major Obstetric Complications: Practical Advice on Volunteering to

Health  1196 Prevention and Management in Work Overseas  1207
Maternal Health and the Burden of Death Resource-Poor Countries  1205 Respect  1208
and Disability  1196 Postpartum Hemorrhage  1205 Realism  1208
Sexual and Reproductive Preeclampsia/Eclampsia  1205 Health Care Staff  1208
Health  1201 Sepsis  1206 Research  1209
Unintended Pregnancy  1201 Human Immunodeficiency Virus and Predeparture Preparation  1209
Contraception  1202 Malaria  1206
Induced Abortion  1203 Obstructed Labor and Obstetric
Improving the Reproductive Health and Fistula  1206
Well-Being of All Mothers  1204 Cesarean Delivery  1207

KEY ABBREVIATIONS
Acquired immune deficiency syndrome AIDS
Cesarean delivery CD
Contraceptive prevalence rate CPR
Female genital mutilation/cutting FGM/C
Global Library of Women’s Medicine GLOWM
Gross national income GNI
Human immunodeficiency virus HIV
International Conference on ICPD
Population and Development considering working abroad for longer or shorter periods
International Federation of FIGO
Obstetricians and Gynecologists
Intrauterine device IUD
Long-acting reversible contraception LARC
Low-income country LIC
Millennium development goal MDG
Middle-income country MIC
Maternal mortality ratio MMR
Nongovernmental organization NGO
Postpartum hemorrhage PPH
Sexually transmitted infection STI
Traditional birth attendant TBA
Tuberculosis TB
World Health Organization WHO
United Nations UN
MATERNAL AND REPRODUCTIVE HEALTH
This chapter can only touch the surface of the complex issues
relating to the continuing yet avoidable tragedy of maternal
deaths worldwide. However, for those readers for whom it pro-
vides the impetus for more in-depth study, many key documents
and papers are contained within its references. First, we offer a
brief description of the main clinical, health system, and wider
social causes and key actions for the prevention of deaths and
obstetric complications, particularly in resource-poor countries,
and conclude with a summary of the steps that need to be taken
at individual, professional, facility, and health system levels and
nationally and internationally to help reduce these needless
deaths. The section after that provides clinical details on the
challenges of preventing, identifying, and managing the main
obstetric complications of pregnancy in resource-poor settings,
and the final section provides some practical tips for anyone
of time.
Maternal Health and the Burden
of Death and Disability
“Many Births Mean Many Burials”
—Kenyan Proverb
Every year worldwide, around 290,000 mothers and 3 million
babies die at the time of birth, and another 3 million infants are
stillborn. Despite recent initiatives, which in some countries
have resulted in declines in maternal death rates over the past
few years, too little has happened too late. The fact is that the
main causes of maternal death and preventive or remediable
interventions have been well known for many years, and nearly
all of these vulnerable mothers could be saved at little extra cost.
Lives would be saved if women had a choice about becoming
pregnant, and once pregnant, if they and their babies had access
to essential health services that provide evidence-based, techno-
logically appropriate, and affordable interventions even in the
poorest countries of the world. This in turn depends on the
availability of resources and the recognition and enforcement of
the human rights of girls and women. For example, a recent
United Nations (UN) report estimated that if all women who
actually wanted to avoid pregnancy were able to access and use
an effective method of contraception, the number of unintended

1196
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 Chapter 58  Improving Global Maternal Health: Challenges and Opportunities
pregnancies would drop by 70%, and the number of unsafe
abortions would drop by 74%. Further, if these women’s con-
traceptive needs were met, and if all pregnant women and their
newborn babies received the basic standards of maternity care
recommended by the World Health Organization (WHO), the
number of maternal deaths would fall by two thirds—from
290,000 down to 96,000—and the number of newborn deaths
would fall by more than three quarters, down to 660,000.1
Deaths are merely the tip of the iceberg. Globally it is
estimated that over 300 million women are living with short-
or long-term pregnancy-related complications with around
20 million new cases occurring each year.2,3 These figures do
not reflect other additional yet poorly recognized burdens. In
most countries postnatal depression, suicide from puerperal psy-
chosis, and other mental health issues are not even acknowl-
edged as pregnancy-related problems, and the stories of legions
of women dying or suffering from these debilitating conditions
remain untold.
Babies are affected by their mother’s health in pregnancy and
birth, and added to the 6 million who die before or just after
birth, many more millions are left motherless and less able to
thrive. The risk of death for existing children under 5 is doubled
if their mother dies in childbirth, which is particularly challeng-
ing for girls.4
Every maternal death or long-term complication is not only
a tragedy for the mother, her partner, and her surviving children,
it is also an economic loss to her family, community, and society.
Saving mothers lives is also crucial to the wider economy; for
example, in Nigeria during 2005, it was estimated that maternal
deaths alone led to around $102 million in lost productivity.5
A Place Between Life and Death
In developed countries, pregnancy is not generally considered as
dangerous, and childbirth is usually regarded as a joyful and
positive life-changing event. However, these 11 million births
account for only 8% of the annual deliveries worldwide. The
same cannot be assumed for the 92% of mothers, some 124,000
million women, living in less developed areas of the world. Of
these, approximately 800 will die and 16,000 will suffer severe
and long-lasting complications every day.6,7 Additionally, every
day, nearly 8000 babies will die around the time of birth, and
another 7000 will be stillborn.8 Overall, this burden of mater-
nal and neonatal mortality, including stillbirths, accounts for
around 15,800 deaths each day, or 10 lives lost every minute.
In Chichewa, the national language of Malawi, the word
pakati refers to pregnancy. Its literal translation means “in the
middle between life and death.” In other African countries, it is
common to hear women in labor using euphemisms such as “I
am going to the river to fetch water; I may not come back,” or
childbirth is described as “slipping on a banana skin at the edge
of a cliff with no safety net.”
These concerns are all too real for many women, and “a place
between life and death” is an accurate description of the 9
months of anxiety and fear that accompany pregnancy and
delivery. The World Bank classifies every economy as low,
middle, or high income; it uses gross national income (GNI)
per capita because GNI is considered to be the single best indica-
tor of economic capacity and progress. Low-income and middle-
income economies are collectively referred to as developing
economies. For the 11 million mothers in high-income countries
(HICs), access to quality antenatal, intrapartum, and postnatal
care for both mothers and babies is readily available. Another
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1197
34 million women will deliver in middle-income countries
(MICs), where hospital facilities with variable quality of care or
resources such as staff, blood, drugs, or high dependency units
may be available. However, for the 90 million mothers in low-
income countries (LICs), the situation can be very different,
with little or no access to even basic health care, which places
the health of both mother and baby at significantly higher risk.
The film “Why Did Mrs. X Die: Retold” is available online in
several languages (vimeo.com/50848172), and it provides a
simple introduction.
Where Mothers Die
Of all the maternal deaths that occur, 99% are in low and
middle-income countries, the same as for newborns.6,9 The
WHO defines the maternal mortality ratio (MMR) as the
number of direct and indirect maternal deaths per 100,000 live
births during pregnancy or up to and including 42 days after
the end of pregnancy. The latest UN estimates for 2013 are
that the overall global MMR is 210 deaths per 100,000 live
births, with an even higher figure (230) for developing
regions (LICs and MICs) compared with 12 for developed
regions. The highest regional MMR is 520 for sub-Saharan
Africa, followed by 190 for both the Caribbean and Oceania,
170 for Southern Asia (which drops to 140 if India is excluded),
77 for Latin America, 60 for North Africa, and 39 for Central
Asia.6 However, these figures hide wide intercountry and intra-
country variations. Overall, Sierra Leone is estimated to have the
highest MMR (1100), followed by Chad (980), the Central
African Republic (880), and Somalia (850). Ten other African
countries have MMRs higher than 500 per 100,000 live births.
Due to the sheer weight of its population, the annual deaths of
50,000 mothers in India account for 17% of the global total.
This is despite the country having made significant progress in
recent years with a concerted effort at national, state, and local
levels: the Indian MMR fell from 600 in 1990 to 200 in 2010.6
Adolescent Girls and Lifetime Risk of Maternal Death
Ending child marriage is a public health priority. Apart from
taking away their childhood, young pregnant girls are more
likely to die and are at greater risk of complications. Those under
the age of 15 are five times more likely to die of a pregnancy-
related cause than women in their twenties.10 Every year, 3
million undergo unsafe abortions.9,11 Maternal death is now the
leading cause of death for young girls in developing countries,
with 15% percent of all deaths worldwide occurring among
adolescents.9,11-13 Compared with mothers aged 20 to 24 years,
girls aged between 10 and 19 years have higher risks of obstructed
labor, eclampsia, puerperal sepsis, systemic infections, and
preterm deliveries and require more cesarean deliveries.14,15 Their
babies also fare worse as a result.
In developing countries, a 15-year-old girl faces a 1 : 160
risk of dying from a pregnancy-related complication during
her lifetime, and this rises to an average risk of 1 : 38 for those
who live in sub-Saharan Africa. The average risk in the most
developed countries is 1 : 3750. In the very worst countries to
be born a girl—such as Chad, Niger, and Côte d’Ivoire—the
lifetime risk is still between 1 : 15 and 1 : 29 despite the fact that
these figures have actually been halved over the past 10 years.6
Even in the developed world, wide variations are seen within a
country depending on who the mothers are, where they live, and
their social circumstances. In the United Kingdom, for example,
vulnerable unemployed women are 10 times more likely to die
1198 Section VII  Legal and Ethical Issues in Perinatology
or suffer complications than women in families where at least
one member is employed.16
United States
The WHO estimated the overall MMR for the United States
to be 28 per 100,000 live births in 2013, which is threefold
greater than in Western Europe and Australasia.6 Indeed, the
United States is one of the few countries whose MMR has
increased, rather than decreased, in recent years. This may be
due to a steady rise in the number of women with advanced
maternal age, chronic medical conditions, and obesity coupled
with an increasing number of medical interventions, not all of
which may be necessary. Recent patient safety research demon-
strates that where consistent protocols for diagnosis, manage-
ment, consultation, or referral of complicated cases are lacking,
less optimal maternal outcomes may result.17
In the United States, as in many Western countries, the most
common obstetric conditions resulting in severe maternal mor-
bidity or mortality are obstetric hemorrhage, severe preeclamp-
sia, and venous thromboembolism.18 Recent case reviews have
highlighted that a significant proportion of the morbidity and
mortality from these conditions are due to missed opportunities
to improve maternal outcomes. A major challenge is to identify
those women who need specialist care at an early stage, without
eliminating the category of lower-risk cases. To address this
complex problem, a multidisciplinary group of senior health
care and birth facility leaders to review and amend current rec-
ommendations and plan a national approach to implement
improved strategies has recently been convened as the U.S.
National Partnership for Maternal Safety.19
Mothers Who Survive: Severe Maternal Morbidity
Whereas global maternal deaths may have been neglected until
relatively recently, women who suffer from severe maternal mor-
bidity and its long-term sequelae have fared even worse. It is
estimated that 1.1 million of the annual total of 136 million
births are complicated by a severe maternal “near-miss”
event, after which the mother survived either by chance or
following high-quality medical care. A further 9.5 million
women suffer more manageable complications that are still very
severe, and 20 million mothers suffer longer-term complications
each year.3 These are conservative estimates.20
Whatever the death-to-disability ratio, as with maternal
deaths, the numbers will always be too high, and the underlying
causes are disturbingly similar. Hence, reducing the risk factors
for death will help to decrease the number of significant obstetric
complications. Table 58-1 estimates the overall numbers and
case fatality rates for the five major global direct obstetric com-
plications of pregnancy and the overall numbers of women
TABLE 58-1 ESTIMATED NUMBERS AND INCIDENCE OF THE MAJOR GLOBAL CAUSES OF DIRECT MATERNAL
DEATHS AND SEVERE MORBIDITY FOR THE YEAR 2000
INCIDENCE OF COMPLICATION
CAUSE (% OF LIVE BIRTHS)
Hemorrhage 10.5
Sepsis 4.4
Preeclampsia, eclampsia 3.2
Obstructed labor 4.6
Abortion 14.8
Modified from AbouZahr C. Global burden of maternal death. In British Medical Bulletin. Pregnancy: Reducing Maternal Death and Disability. British Council. Oxford University Press;
2003, pp. 1-13.
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affected.21 Direct maternal deaths are those that result from
obstetric complications of the pregnancy state (pregnancy, labor,
and the puerperium), from interventions, omissions, incorrect
treatment, or from a chain of events resulting from any of the
above. Indirect obstetric deaths are those that result from previ-
ous existing disease or disease that developed during pregnancy
and which was not due to direct obstetric causes but was aggra-
vated by physiologic effects of pregnancy. Coincidental mater-
nal deaths are those from unrelated causes that happen to occur
in pregnancy or the puerperium. Late maternal deaths include
the death of a woman from direct or indirect obstetric causes
more than 42 days but less than 1 year after termination of
pregnancy.
As stated by Zacharin, “In an unequal world, these women
are the most unequal among unequals.”22 Of all the long-term
morbidities arising from childbirth, an obstetric fistula is one of
the worst. It is estimated that in sub-Saharan Africa and in parts
of Asia, between 654,000 to 2 million young women live,
usually in isolation and shame, with untreated obstetric fistulae;
the annual incidence is 50,000 to 100,000 new cases.23,24
Obstetric fistulae are highly stigmatizing, and affected women
often become social outcasts. The constant leakage of urine and
or fecal matter makes it difficult for them to remain clean,
especially in areas with limited access to water, and they most
likely will never have children. It is hard to find work; and
having failed in their primary objective to have children, they
offer little, if any, economic advantage to their families. As a
result they are frequently rejected and cast out. The growth in
training local surgeons in techniques for simple repair and the
ever increasing number of specialist fistula repair centers who
also train local staff is slowly helping restore function, fertility,
and dignity to these women—but the services available are still
few and far between. This is discussed in more depth in the
section “Obstructed Labor and Obstetric Fistula.”
Babies Who Die
Mothers and their babies are a dyad, inextricably linked, yet all
too often the newborn is overlooked when considering policies
to reduce the impact of maternal ill health or death. Around
half of the annual 2.6 million stillbirths and 2.9 million
deaths in the neonatal period, the first month of life, occur
as a result of maternal complications during pregnancy or
delivery.8 Thus improving maternal care helps more babies
survive, and they survive in better condition, which provides a
healthier start to life.
Most neonatal deaths (73%) occur during the first week
of life with around 36% in the first 24 hours. The major
causes are complications that arise from preterm birth (36%),
intrapartum asphyxia (23%), and neonatal infections such
NUMBER CASE FATALITY % OF ALL
OF CASES RATE (%) DEATHS DIRECT DEATHS
13,795,000 1.0 132,000 28%
5,768,000 1.3 79,000 16%
4,152,000 1.7 63,000 13%
6,038,000 0.7 42,000 9%
19,340,000 0.3 69,000 15%
 Chapter 58  Improving Global Maternal Health: Challenges and Opportunities
as sepsis, meningitis, and pneumonia, which together con-
tribute 23%.25 Two thirds of newborn deaths could be pre-
vented if skilled health workers performed effective interventions
at birth and during the first week of life.26
Labor and the 24 hours surrounding birth are the riskiest
times for mother and baby, with 46% of maternal and 40%
of neonatal deaths and stillbirths occurring during this
period.27 This fuels the repeated call for more skilled birth
attendants to assist at delivery, which should take place in a clean
and well-equipped unit with working transport links to more
comprehensive facilities capable of managing emergency com-
plications for both mother and baby.
Why Mothers Die
CLINICAL CAUSES
In the most recent WHO analysis of the global causes of mater-
nal death, 73% of the deaths were considered to be due to direct
obstetric causes. Of all direct and indirect deaths combined,
27% were due to hemorrhage, 14% to preeclampsia, 11% from
puerperal sepsis, 8% from unsafe abortion, 3% from embolism,
3% from obstructed labor, and 7% from other direct causes
combined.28 Virtually all these deaths could be avoided if the
maternal and reproductive health services taken for granted in
developed countries were available. The other 27% of maternal
deaths worldwide are due to indirect causes, most of which result
from preexisting underlying medical disorders exacerbated by
the mother’s pregnant state.
Deaths from illnesses related to human immunodeficiency
virus (HIV) and acquired immune deficiency syndrome
(AIDS), regarded as indirect deaths, make a major contribu-
tion to maternal mortality globally and in some sub-Saharan
countries cause more than half of all indirect deaths. In
Botswana they account for 56%, and in South Africa and
Namibia, the rates are 60%, rising to 67% in Swaziland.6 In four
non-African countries—Ukraine, Bahamas, Thailand, and the
Russian Federation—more than 20% of indirect deaths are due
to HIV, with the majority being linked to intravenous (IV) drug
use.6 A recent survey predicted that 12% of all deaths during
pregnancy and up to 1 year after delivery will result from an
HIV-positive pregnancy prevalence rate of 2% and that the
MMR will increase to 50% in areas with an HIV-positive preg-
nancy prevalence rate of 15%.29
In developed countries, indirect deaths predominate. The
latest U.K. Confidential Enquiry into Maternal Deaths also
reported that two thirds of the maternal deaths between the
years 2009 and 2012 were due to indirect causes. The risk of a
maternal death in the United Kingdom has significantly fallen
over the past 10 years from already small numbers. The com-
parative U.K. MMR, calculated using WHO methods, is now
5.35 deaths per 10,000 live births.30 The majority of the reported
indirect deaths were due to severe medical and mental health
problems becoming complicated by pregnancy, such as preexist-
ing cardiac disease, epilepsy, autoimmune disease, and suicide.
These causes are now being bolstered by conditions adversely
affected by poorer lifestyles such as acquired cardiac disease,
hypertension, type 2 diabetes, liver disease, alcohol and drug
dependency, and other disorders associated with obesity.30
HEALTH SYSTEM FACTORS
A lack of health system planning and resources is one of the
largest contributors to the continuing pandemic of maternal
ill health and mortality. Many women receive no antenatal care
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1199
BOX 58-1  BASIC EMERGENCY OBSTETRIC
NEWBORN CARE
Basic emergency obstetric and newborn care is critical to
reducing maternal and neonatal death. This care, which
can be provided with skilled staff in large or small health
centers, includes the capabilities for:
• Administering antibiotics, uterotonic drugs (oxytocin),
and anticonvulsants (magnesium sulfate)
• Manual removal of the placenta
• Removal of retained products of conception following
miscarriage or abortion
• Assisted vaginal delivery, preferably with vacuum
extractor
• Basic neonatal resuscitation care
Comprehensive emergency obstetric and newborn care,
typically delivered in hospitals, includes all the basic func-
tions above, plus capabilities for:
• Performing cesarean delivery
• Safe blood transfusion
• Provision of care to sick and low-birthweight newborns,
including resuscitation
at all, and the WHO estimates that only 38% of mothers in
low-income countries receive the minimum four antenatal visits
they recommend.31,32 Less than 50% of all women give birth
accompanied by a skilled attendant, such as a midwife or
doctor,33 and many lack access to facilities with staff and resources
capable of providing basic emergency obstetric or newborn care
(Box 58-1) or to higher level services capable of dealing with
serious complications or emergencies, such as undertaking life-
saving cesarean delivery (CD) for mother or child.34
A recent WHO study showed 54 countries that had CD
rates lower than 10%, the minimum standard for safe moth-
erhood services, and 69 had rates higher than 15%, all unac-
ceptably high. In 2008, the conservative estimate of the overall
rate for Brazil was 45.9%, and it was 30.3% for the United
States, compared with 0.7% for Burkina Faso.35 The study also
estimated that in 2008, 3.18 million additional CDs were
needed, and 6.20 million unnecessary operations were per-
formed worldwide. The cost of this global “excess” was estimated
to amount to approximately $2.32 billion, whereas the cost of
the “needed” CDs globally was approximately $432 million.
A critical lack of skilled staff, such as midwives and doctors,
is also apparent. It is estimated that the world needs another
350,000 midwives,36 and doctors are also extremely scarce, espe-
cially in the unattractive, remote, and poorer areas of already
resource-poor countries. To help address these shortages, task
shifting—the transferring of skills and competencies to other
trained individuals—is becoming increasingly commonplace. In
some countries such as Mozambique, cadres of ancillary staff
have been trained as clinical officers—nonphysician clinicians—
to perform basic life-saving skills and procedures that include
CD, and the results have been impressive.37
An emerging issue is that of quality of care. To date, much of
the global effort to reduce maternal mortality has focused on
increasing access to care; however, the focus is now shifting
toward improving and standardizing the variable quality of care
that women receive from the health services they have been
encouraged to attend. Clinical guidelines and protocols have
been developed by the WHO and professional associations, and
the use of maternal death reviews to learn lessons to improve
care is also having a positive effect.38
1200 Section VII  Legal and Ethical Issues in Perinatology
VULNERABILITY AND UNDERLYING SOCIAL DETERMINANTS
The underlying causes of maternal mortality are complex and
multifactorial. For example, although a mother in a resource-
poor country may technically be described as dying from a
postpartum hemorrhage, the true underlying causes may be very
different. She may have died because she had no care, or because
she was unable to read the information leaflets about the warning
signs and when or where to seek help. Care may have been avail-
able but beyond her reach physically or financially. Access to any
form of transport in emergency situations is frequently problem-
atic, especially at night. Furthermore, her husband or family
members may have prevented her from attending care or lacked
the money to pay the necessary bribes to secure her treatment.
She may have refused to seek help because she has heard she
would be slapped, shouted at, or treated disrespectfully in the
health facility. Or she may have overcome all of these obstacles
to reach a health care facility only to find poorly trained staff or
no staff at all and no medicines, blood products, or equipment
and no one capable of performing her life-saving operation.
Added to which, she will probably have been in poor physical
condition and suffering from anemia and other chronic health
disorders. Thus the stated clinical factors surrounding a maternal
death provide little or no indication of the underlying causes as
to why the woman really died. Without understanding the
wider “causes of the causes,” the barriers to safe maternity
care cannot be identified and overcome. To help quantify
these, it is common for those who work in the field of inter-
national women’s health to use the “three delays” model as a
checklist to help identify the barriers pregnant women
face.39,40 These barriers may be financial, physical, social, cul-
tural, or medical and may be present in the family, the com-
munity, or the health care system. These are inextricably
interlinked, and some examples are given in Table 58-2.
“CAUSES OF THE CAUSES”
A recent report into inequalities in health outcomes in England,
“Fair Society, Healthy Lives,”41 states that the “causes of the
causes” are the circumstances and societies in which people are
born, grow, live, work, and age. Social position, wealth, and
education help determine each person’s health outcomes and life
expectancy. It estimates that health care services contribute
only one third to improvements in life expectancy and that
improving life chances and removing inequalities contribute
the remaining two thirds. If this is the case in a developed
country, the ratio of inequalities in resource-poor countries must
be far higher. Indeed, whether a pregnant woman lives or dies
is a lottery that depends almost entirely on where she was born
and lives and in what circumstances. Mothers who die are gener-
ally the least visible, most vulnerable, and poorest of the poor.
Although urban poverty is an increasing problem, most maternal
casualties tend to live in rural areas and lack both transport and
access to skilled care in health facilities. They are more likely to
be illiterate or poorly educated, undertake hard manual work,
and find themselves almost permanently pregnant. In societies
where social and economic deprivation is rife, so is the absence
of laws to protect human rights and promote gender equality in
places where those women with the lowest educational achieve-
ments are at greatest risk.42
The lowly status of girls and women frequently means that
they receive the last and least of the family food. General mal-
nourishment, coupled with anemia and micronutrient deficien-
cies, leads to chronic ill health and multiple comorbidities such
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TABLE 58-2 THE THREE DELAYS: EXAMPLES
OF BARRIERS TO SAFE, EFFECTIVE
MATERNAL CARE
Delay in seeking • Traditional beliefs and practices, use of
care traditional birth attendants
• Lack of education and understanding of need
for care or warning signs
• Mother is not decision maker
• Mother has no money and no control over
decisions affecting her life
• Religious custom and practice
Delay in arriving at • No transport
a place of care • No money
• Unofficial bribes
• Services patchy or too far away
• Concerns about physical abuse by staff in labor
• Poor reputation of facilities as “places where
women and babies die”
Delay in providing • Facilities not equipped to provide basic and/or
appropriate emergency obstetric care
quality care • Lack of suitably trained staff
• Poor clinical practice
• Little or no use of evidence-based protocols
and guidelines
• Physical and verbal abuse of women in labor
• Lack of blood, medicines, essential equipment,
and operating theatres
• Frankly harmful care
• Intermittent electricity, water, and so on
Modified from Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc
Sci Med. 1994:1091-1110.
as malaria, HIV, or tuberculosis (TB). These women have little
or no control over their health, being dependent on male or
elder family members to decide whether they should seek care,
even in emergencies. Many will become child brides, become
pregnant, and be forced to give up any form of education.
Female genital mutilation/cutting (FGM/C) is common and
is associated with a higher incidence of obstructed labor, emer-
gency cesarean delivery, fetal distress, obstetric fistula, and per-
manent perineal damage.43 All of these factors lead to complex
pregnancies and higher rates of stillbirth and neonatal death.
WOMEN’S RIGHTS
“Imagine a world where all women enjoy their human rights.
Take action to make it happen.”
—1998 United Nations Campaign for Human Rights
A further, critically important reason why global efforts to
reduce maternal mortality and morbidity have been slow is the
low value that society, political, religious, community, and
family leaders have placed on women’s lives. As the father
of the Safe Motherhood movement, Professor Mahmoud
Fathalla, famously said, “Women are not dying of diseases
we cannot treat … they are dying because societies have yet
to decide that their lives are worth saving.”44
In 1948, the Universal Declaration of Human Rights stated
that “all human beings are born free and equal in dignity and
rights.”45 The 1995 UN Beijing declaration on women’s rights
reported that “the full implementation of the human rights of
women and of the girl child is an inalienable, integral, and indi-
visible part of all human rights and fundamental freedoms.”46 By
2009, the UN Human Rights Council had acknowledged that
preventable maternal mortality was a human rights violation,
and health advocates started using human rights mechanisms to
 Chapter 58  Improving Global Maternal Health: Challenges and Opportunities
make governments honor their commitment to ensure access to
services essential for reproductive health and well-being.
The right to health is a human right, and the health of a
nation is determined by the health of its girls and women.
Healthy women are more likely to fulfill their potential, nurture
healthy families, and contribute to their local and national econ-
omies. Ellen Sirleaf Johnson argued that women’s socioeconomic
empowerment is essential to achieve better health care outcomes,
and she ended her 2011 Nobel Prize acceptance speech with a
challenge: “Nations thrive when mothers survive, we must strive
to keep them alive.”47
The contribution made by mothers to society is far reach-
ing, and countries that fail to protect and promote women’s
rights have the worst economic, educational, maternal, and child
health outcomes. The application of human rights shifts the
understanding of maternal deaths as mere misfortunes that are
acts of fate into injustices that the state is obliged to remedy.
Using a human rights approach provides valuable tools to hold
governments legally accountable to address the preventable
causes of maternal mortality and to distribute resources and
medicines essential for reproductive health, such as effective con-
traception and misoprostol to reduce postpartum hemorrhage.
For example, when the Sri Lankan government introduced
universal education and access to health care, maternal deaths
declined significantly for little extra cost.48 Political will, literacy,
and respect for the status and rights of women in society are
key components for achieving sustainable health improvements.
Nearly 70 years after the Universal Declaration, many women
still struggle to have their basic rights protected. As recently as
2013, objections were raised by certain countries and religious
groups to a potential UN statement reaffirming women’s rights
to education, contraceptive choices, family spacing, and the
introduction of declarations against domestic violence, rape,
child marriage, and FGM/C. Those who objected considered
that upholding these human rights could destroy society by
allowing a woman to travel, work, use contraception without
her husband’s approval, and control her family’s spending. These
may be extreme views, but there are still far too many countries
that turn a blind eye to gender inequalities and violence that
includes child marriage, rape, and FGM/C and who do not
favor girls receiving primary, let alone secondary, education.
Human rights play an important role in the fight to improve
the status of women because they embody a shared set of values
that have been enshrined in law. Infringements can be litigated
in countries that subscribe to them, but even countries that do
not often appear to be sensitive to the charge that they are
infringing the human rights of their population. Where the law
hinders the use of contraception or does not allow induced abor-
tion, health care professionals invariably find it easier to provide
life-saving interventions if they can be reassured that they are
protecting the woman’s right to life, to benefit from scientific
advances, or to avoid discrimination.
Advocacy for women is an obligation for everyone engaged
in reproductive health care. This means that all health care
professionals need to know how to embed human rights
principles into every aspect of their delivery of care. The
International Federation of Obstetricians and Gynecologists
(FIGO) women’s sexual and reproductive rights committee has
developed a comprehensive teaching syllabus that can be adapted
for use by a wide range of professionals. The clinical knowledge
and practical skills required to deliver quality reproductive
health care have been built around a core checklist of 10
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1201
health-related human rights. The result is a competency-based
educational approach that simultaneously advocates for human
rights and health by developing standards for performance and
tools for training teachers and students in both the classroom
and clinical settings. The teaching materials can be freely accessed
and downloaded from the Global Library of Women’s Medicine
(GLOWM).48b Experience from the teaching workshops with
both laypersons and professional audiences confirms that this
approach shifts the teaching of human rights and women’s repro-
ductive health from a marginal to a mainstream position in the
learning process for all health care professionals.
SEXUAL AND REPRODUCTIVE HEALTH
The lack of universal access to basic sexual and reproductive
health services is one of the most significant barriers to reducing
maternal morbidity and mortality globally. As stated at the very
start of this chapter, but worth repeating here, a recent report1
estimated that if all women wanting to avoid pregnancy used
an effective method of contraception, the number of unin-
tended pregnancies would drop by 70%, and unsafe abor-
tions would drop by 74%. If these women’s contraceptive
needs were met, the number of maternal deaths would fall
by two thirds, and newborn deaths would decline by more
than three quarters, and the transmission of HIV from mothers
to newborns would also be virtually eliminated. Furthermore, it
was estimated that contraceptive use averted 272,040 maternal
deaths in 2008 and that meeting unmet need for contracep-
tion could prevent an additional 104,000 deaths per year, thus
preventing a further 29% of maternal mortality.49 This further
reduction by about one third if the unmet need for contracep-
tion were met is similar to estimates reported by others,50 and it
underscores the critical role that access to effective contraception
plays in preventing maternal mortality and morbidity.
Sexual and reproductive health was formally defined at the
1994 International Conference on Population and Development
(ICPD).51 At its core is the promotion of healthy, voluntary, and
safe sexual and reproductive choices for individuals and couples,
including decisions about if, when, and with whom to have
children. It encompasses highly sensitive and important issues
such as sexuality, pregnancy prevention and abortion, gender
discrimination, and male/female power relations. Its full attain-
ment depends on the protection of human and reproductive
rights. The conference also adopted the goal of ensuring univer-
sal access to sexual and reproductive health as part of its frame-
work for a broad set of development objectives and Millennium
Development Goals (MDGs) and set very similar objectives in
their Target 5:B.52 Despite these initiatives, an estimated 85
million unintended pregnancies occurred in 2012.53
Unintended Pregnancy
An unintended pregnancy is one that is mistimed, unplanned,
or unwanted at the time of conception,54,55 and such pregnan-
cies are associated with an array of negative health, economic,
social, and psychological outcomes for women and children.56-60
In 2012, the global unintended pregnancy rate was 53 per 1000
women aged 15 to 44, with the highest rates in Eastern and
Middle Africa (108 each) and the lowest in Western Europe
(27).1 Of these 85 million unintended pregnancies, 50% will
end in termination,1 which corresponds to about 1 in 5 of all
pregnancies and contributes to the pandemic of unsafe abor-
tion.61 A further 13% will end in miscarriage, and 38% will
1202 Section VII  Legal and Ethical Issues in Perinatology
result in an unplanned birth.1 Four out of five pregnancies in
the developing world occur among women with no access to
modern effective contraception,59 but even in settings where
contraceptive use is comparatively high, unintended pregnancies
may still occur when the available contraceptive method fails or
because of poor adherence.
Contraception
Voluntary access to family planning—especially modern,
effective contraceptive methods for women and men—is
crucial to directly improving health outcomes and is posi-
tively associated with improvements in educational and
economic status.49,50,62,63 The health benefits include sizable
reductions in maternal, newborn, and child morbidity and mor-
tality as well as deaths and complications that arise from unsafe
abortion.60,49,63 At the household level, improved access to family
planning services leads to substantial improvements in women’s
earnings and children’s schooling.62 Nationally, higher levels of
uptake correlate with lower fertility rates, which enhance eco-
nomic growth.62,64 Conversely, high levels of unwanted fertility
correlate with poverty and inequality.65
Barriers to contraceptive usage can also be categorized accord-
ing to the three-delay model described earlier38 and can occur
at the client, health care provider, and health systems level.
The most frequently cited reasons for nonuse among women is
poor understanding of their risk for pregnancy, concerns about
possible side effects, infrequent sexual activity, service fees, or
opposition; in the latter, desires of a male partner or religious
or cultural reasons are cited. Married women may have little
control over contraceptive decision making, which is particularly
important when partners differ in their childbearing preferences.
Unmarried women frequently have to face strong stigma from
judgmental providers if they are sexually active, which in turn
reduces these women’s ability to obtain needed services. At the
provider level, barriers include lack of knowledge or skills, moti-
vation, and bias for or against certain methods, such as intrauter-
ine devices (IUDs). Limiting the provision by certain provider
types also blocks uptake: for example, only allowing doctors to
insert IUDs or imposing non–evidence-based restrictions on
when a method can be started, such as commencing only at the
time of menses. Common health system barriers include inad-
equate human and financial resources and a failure to integrate
family planning with other core services such as maternity and
child health clinics, delivery, postnatal or postabortion care, and
HIV services. Access may also be limited through geographic
constraints and lack of equipment and supplies. Shortages of
supplies are very common, especially in rural areas. In addition
to overcoming provider bias, lack of competency, and health
systems issues, most low-resource settings are still in need of
educational interventions to increase awareness and understand-
ing for the community as a whole, thereby reducing many of
the existing barriers to effective contraceptive use.
Contraceptive prevalence is typically defined as the percentage
of women who are currently using, or whose sexual partner is
currently using, at least one method of contraception regardless
of the method used; usually, it is reported for married or in-union
women (women in a stable sexual relationship) aged 15 to 49.
In recent decades, general increases in contraceptive preva-
lence rates (CPRs) have been seen in most areas of the world,
and globally, they increased from 53% in 1990 to 57% to
64% in 2011 through 2012.66-71 However, CPRs remain
extremely low in parts of Africa with regional estimates of 32%,
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19%, and 15% in Eastern, Middle, and Western Africa, respec-
tively,68 giving a rate of 24% to 30% for Africa overall.66-71 Wide
intercountry variations are also apparent: for example, since
1990, progress in contraceptive use has been made in Rwanda
(18% to 50%), Malawi (12% to 45%), and Tanzania (11% to
34%); yet in Sierra Leone and Nigeria, the CPRs for 2010 were
6.7% and 8.6%, respectively.68 In Southern Africa, rates are now
relatively high at 62%, having risen from 47%, and in Southern
Asia, rates have risen from 36% to 50% in India and from 34%
to 61% in Bangladesh; in addition, substantial gains have been
made in Latin America, where the regional CPR is now 73%.68
Although high and most stable in Europe and North America
(72% to 78%), the rates are highest in East Asia, largely attribut-
able to China (83%).68 Nevertheless, the overall global CPR
remains low, and this is a serious obstacle to further improving
women’s health.
Unmet need for family planning is typically defined as the
percentage of women who want to stop or delay childbearing
but who are not using any method of contraception to prevent
pregnancy. A more useful definition regards both women who
use no method or women who use traditional methods as having
an unmet need for modern methods, not only because tradi-
tional methods have high use-failure rates, but also because,
although some women using traditional methods might choose
to use these methods, such choices often imply that women
perceive other options to be unavailable, or are not fully informed
of contraceptive options.71
The unmet need for contraception is unacceptably high.
Globally, 222 million women who would prefer and are trying
to limit or space their pregnancies are not using contracep-
tion.70,71 Around three-quarters of these women live in the
world’s poorest countries,72 and the unmet need remains greatest
in sub-Saharan Africa (60%) and West and South Asia (50%
and 34%, respectively) with disproportionately high levels
among illiterate, poor, adolescent, and rural women.58,50
The postpartum period is crucially important for contra-
ceptive intervention because rapid repeat pregnancies are
associated with poor maternal and infant outcomes. An anal-
ysis of data from 27 countries found that 95% of women who
were 12 or fewer months postpartum did not want another birth
within 2 years, yet 65% of them were not using contraception.73
Similarly, although most women being treated for complications
of induced or spontaneous abortion are in need of effective
contraception, data from 17 low-resource countries show that
only 1 in 4 of these women were discharged from care with a
method in place.74
Contraceptive Methods
The type of contraceptive method used is also variable, but
choice is critical in relation to efficacy and continued usage,
particularly in areas where women find it difficult to attend
clinics, or where the service is unavailable or limited by shortages
and failure of supplies. Traditional contraceptive techniques
such as withdrawal and fertility awareness (natural family plan-
ning) are the least effective. The emphasis should be on enabling
women and their partners to have access to a wide range of the
most effective modern methods. WHO classifies contraceptive
methods into effectiveness tiers, which are described in Table
58-3. The effectiveness of the method is critically important
for reducing the risk of unintended pregnancy and can be mea-
sured either with “perfect use,” when the method is used cor-
rectly and consistently as directed, or with “typical use,” which
 Chapter 58  Improving Global Maternal Health: Challenges and Opportunities 1203

TABLE 58-3 EFFECTIVENESS OF CONTRACEPTIVE condom, male or female, along with a highly effective nonbarrier
METHODS BASED ON TYPICAL USE method such as hormonal contraception, the copper-bearing
FAILURE RATES IUD, or sterilization. Male and female condoms are the only
contraceptive methods available that also protect against sexually
Tier 1 Methods: The Most Effective, Resulting in Less Than 1
Pregnancy per 100 Women in a Year transmitted infections (STIs) and HIV; hence using a dual-
Permanent contraceptive Male and female sterilization contraceptive method should be promoted routinely in areas of
methods high STI/HIV prevalence.
Long-acting reversible Intrauterine devices (copper bearing or Short-acting methods such as condoms and oral and
contraceptives levonorgestrel [LNG] IUDs are effective
(LARCs) for 5 to 10 years depending on the IUD)
injectable contraceptives are the most commonly used
Subdermal implant (progestogen only, methods in sub-Saharan Africa despite the fact that perma-
effective for 3 to 5 years depending on the nent and LARC methods are much more effective at prevent-
implant) ing pregnancy.76-78 A recent modeling study concluded that if
Tier 2 Methods: Result in 6 to 12 Pregnancies per 100 Women in a Year just 20% of the women in sub-Saharan Africa currently using
Shorter-acting Injectable contraceptives
contraceptive Progestogen-only injectable contraceptive oral contraceptive pills and injectables were to switch to using
methods (requires reinjection every 8 weeks the more effective subdermal implant, 1.8 million unintended
(norethisterone enanthate [NET-EN]) or pregnancies, 576,000 abortions (many of them unsafe), and
12 weeks (depot medroxyprogesterone 10,000 maternal deaths would be averted over 5 years.78 Encour-
acetate, [DMPA])
Oral contraceptives
agingly, efforts to achieve the ambitious goal of the 2012
Combined oral contraceptive pill (COC; London Summit on Family Planning—to enable an additional
estrogen/progestogen) 120 million women and girls in the world’s poorest countries to
Progestogen-only pill (POP) access and use lifesaving family planning information, services,
Other methods and supplies by 2020—appears to be gaining momentum.79
Combined vaginal ring (estrogen/progestogen;
the ring is left in the vagina for 3 weeks
and then is not used for 1 week) Induced Abortion
Combined patch (estrogen/progestogen; a Even though deaths from unsafe abortion worldwide dropped
new patch is applied once a week every from 69,000 in 1990 to 47,000 in 2008, the consequences of
week for 3 weeks and then is not used for
1 week)
unsafe abortion remain one of the five leading causes of
Female diaphragms maternal mortality.80 However, although the actual numbers
Tier 3 Methods: Result in 18 or More Pregnancies per 100 Women in a may have declined, the proportion of women who die of unsafe
Year abortion has remained stubbornly unchanged at around 9% to
Shorter-acting methods Condoms (male or female) 13% of maternal deaths.28,80 Such deaths can be largely pre-
of least contraceptive Fertility awareness–based methods
efficacy Spermicides vented by the provision of safe abortion services offered by
trained staff working within an enabling legal framework. Where
Modified from World Health Organization (WHO). WHO Department of Reproductive the in-country laws prevent offering this service, many lives can
Health and Research, Johns Hopkins Bloomsbury School of Public Health/Center for
Communications Programs (CCP). Knowledge for health project. Family planning: a still be saved by introducing accessible, nonjudgmental, and
global handbook for providers (2011 update). Baltimore/Geneva: CCP and WHO, 2011; prompt care for the identification and management of the com-
and Hatcher RA, Trussell J, Nelson AL, Cates W, Kowal D, Policar M (eds).
Contraceptive Technology. 20th revised edition. New York: Ardent Media; 2011.
plications of clandestine unsafe abortions. Only 40% of the
world’s women have access to safe and legal abortion services
within set gestational limits. Elsewhere, access is either absent
or is restricted to a lesser or greater degree.81
reflects real-world actual use, including inconsistent and incor- Globally each year, around 44 million abortion procedures
rect use.75 take place; about half are unsafe, and the vast majority are due
Sterilization, almost exclusively female, is most commonly to unintended pregnancies.82 Unsafe abortions include those
used in Asia and Latin America. IUDs account for a third of undertaken by unskilled providers under unhygienic conditions,
contraceptive use in Asia and are the most commonly used those that are self-induced by the woman inserting a foreign
method in some parts.70 Injectables are the most widely used object into her uterus or consuming toxic products, and those
methods in sub-Saharan Africa and also in Southeast Asia.70 Oral instigated by physical trauma to a woman’s abdomen.83 Nearly
contraceptives make up nearly half of total contraceptive use in all unsafe abortions (98%), and the deaths that arise as a conse-
northern Africa, whereas male condoms are the most common quence (99.8%), occur in developing countires.83 About two
method in Central and Western Africa.72 thirds of abortion-related deaths occur in sub-Saharan Africa,
The subdermal implant and IUD are the most effective and one third occur in Asia.83 In high-resource regions of the
reversible contraceptive methods available and are highly world where safe and legal abortion services are provided,
suitable for resource-poor countries because they have failure deaths are extremely rare.83 The majority of women who seek
rates of less than 1% for both perfect and typical use.75 The these procedures in resource-poor countries, where it is usually
failure rates for these methods are very low because they do not illegal, will already have had a number of pregnancies. They
require any additional user intervention. Injectable contracep- frequently view their decision to seek an abortion as a last
tives, oral contraceptive pills, the hormonal patch, and the resort—a necessary respite from the exhaustion of incessant
vaginal ring all have failure rates of less than 1% with perfect childbearing that has left them in very poor health in addition
use; however, with typical use, these methods are only 90% to to their family circumstances leaving them with no resources,
94% effective.75 Condoms are 98% effective with perfect use, food, or money to care for another child.
but the method failure rate increases to 18% to 21% with typical Deaths and disability from unsafe abortion continue to occur,
use.75 Dual contraception is defined as the consistent use of a despite major advances in the availability of safe and effective

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1204 Section VII  Legal and Ethical Issues in Perinatology
technologies for medically induced abortion, which additionally
reduce operative interventions.84 Complications and causes of
death from unsafe abortion include hemorrhage, sepsis, and
peritonitis in addition to trauma to the cervix, vagina, uterus,
and abdominal organs.85 Apart from the risk of death, one in
four women who undergo an unsafe procedure—an estimated
5 million each year—are likely to develop temporary or life-long
disability that requires medical care and includes secondary
infertility.79,83,86
Induced abortion has existed in all societies since the dawn
of time, and evidence shows that wherever they live, and whoever
they are, many women will seek an abortion when faced with
an unintended pregnancy, irrespective of the legal circum-
stances.83,84 For example, the abortion rate of 29 per 1000
women of reproductive age in Africa, where it is mostly illegal,
is similar to that of 28 per 1000 women in Europe, where abor-
tion is generally permitted on broad grounds but with limits for
gestational age.81 Where abortion is allowed, very few women
resort to unsafe practices, and as a result, morbidity and mortal-
ity are extremely low. When made legal, safe and accessible,
women’s health improves rapidly. In South Africa, for example,
the annual number of abortion-related deaths fell by 91% after
the liberalization of the abortion law in 1996.87 When provided
in a safe environment by properly trained providers, abortion is
one of the safest medical procedures.83
Reducing the number of unsafe abortions or promptly iden-
tifying and managing their complications are global health pri-
orities. Universal access to legal, safe services for all women is
unlikely to be achieved because of the diverse moral, religious,
and other contextual issues. It is a highly divisive subject with
no easy answers. Nevertheless, whatever stance is taken at a
personal, national, or legal level, helping women who are suffer-
ing and dying of the complications of unsafe procedures must
be part of all programs designed to reduce maternal deaths and
disabilities. The first step is to accept that this key health issue
should not be swept under the carpet as an inconvenient truth.
The second is to develop a program for the management of
complications through evidence-based and nonjudgmental
national strategies such as the one published in Kenya in 2012
by the Ministry of Medical Services.88 Bringing the issue of
abortion out into the open and acknowledging the problem will
go a long way in helping to save lives.
Improving Reproductive Health and
Well-Being of All Mothers
Despite intense efforts at many levels, improving the acces-
sibly and quality of care for all of the world’s mothers and
babies remains a monumental task. Progress has been made,
however, in that maternal deaths rates fell 45% between
1990 and 2013 globally. However, in many pockets of
the world, rates continue to stagnate or rise, such as in the
United States.6 The international spotlight shone brightly on
the problem when Millennium Development Goal 5, agreed to
by all UN member states in 1990, challenged low- and middle-
income countries to reduce their maternal mortality by 75% by
2015, but now that time has come, and the targets—perhaps in
hindsight too ambitious—remain largely unmet.52,89 The UN
has now agreed to new targets, the Sustainable Development
Goals, and as currently drafted under Goal 3, “To ensure healthy
lives and promote well-being for all at all ages,” they propose that
by 2030, the overall global MMR should be reduced to less than
70 per 100,000 live births, and preventable neonatal deaths
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should be eliminated.90 These hugely challenging targets will not
be met unless action is taken at all levels, and in all sectors, to
implement the necessary and fundamental changes that have
been described in this chapter. A recent report estimated that
increased coverage and improvement in the quality of mater-
nity services by 2025 could avert 71% of neonatal deaths,
33% of stillbirths, and 54% of maternal deaths at a cost of
$1928 for each life saved.91 Furthermore, is estimated that
contraceptive use averted 272,040 maternal deaths in 2008 and
that meeting unmet need for contraception could prevent an
additional 104,000 deaths per year.49
Making health care welcoming and accessible to all women
through improving transport links and eliminating or reducing
user fees, scaling up the number of health facilities capable
of providing basic emergency and comprehensive emergency
obstetric and neonatal care, and increasing the numbers facilities
with caring, well-trained midwives, doctors, and other health
workers is essential. Developing a culture of quality care must
accompany the implementation of appropriate clinical guide-
lines and protocols, which the WHO and others have already
produced, and audits and reviews must be used to assess progress
and identify and rectify problems that may be identified.
Improving communications and providing a woman with holis-
tic and comprehensive coordinated care during the continuum
of her pregnancy—preconception, antenatal, intrapartum, and
postnatal care along with postpartum family planning—will also
prove crucial. Apart from addressing the clinical quality of care,
well-conducted maternal or perinatal death or morbidity reviews
also provide in-depth evidence of the underlying reasons why
mothers may be dying. Here, their results help not only in the
development of accessible maternal and reproductive health ser-
vices but also with improvements to education and human
rights.
Sustained pressure and advocacy for beneficial change,
together with leadership and realistic and practical policies,
are required from world leaders and influencers, the UN,
other international organizations, nongovernmental organiza-
tions (NGOs), national governments, and national and local
policymakers. Ministers of finance, law, education, transport,
and health all need to play their part through enacting human
rights legislation, promoting and funding education for girls,
and providing better transport links and more medicines, com-
modities, and other supplies. Essential drugs such as magnesium
sulfate are often unavailable or in very short supply, as are blood
and fluid replacement, equipment, laboratory reagents, and even
generators and clean water. Ministries of health can supply more
and better equipped facilities capable of providing care at all
levels, and they can create training schools for the extra mater-
nity staff so badly needed in most of the world.
National and local professional associations and individ-
ual health care workers can improve the quality of care they
provide through the use of evidence-based practice and the
development of situationally appropriate clinical guidelines
and technologies. They can also ensure continual professional
updating and training. Until such time as there are enough
midwives and doctors, intermediate-level health care workers
trained to undertake tasks traditionally performed by doctors
play an invaluable role. A functioning health system also requires
an efficient system of communication, referral, and transport.
Underpinning and facilitating all of this work should be a sup-
portive national legal and ethical framework that includes poli-
cies that strive for equality in women’s rights. This is not
 Chapter 58  Improving Global Maternal Health: Challenges and Opportunities
BOX 58-2  TWELVE PROPOSITIONS FOR SAFE
MOTHERHOOD FOR ALL WOMEN
1. A woman’s life is worth saving.
2. Girls should have equal access to food, education,
health care, and life opportunities as their brothers.
3. Young girls should not be subject to violence
including rape, FGM, and child marriage, and women
should not suffer violence in any form.
4. Women should have an equal say in decisions that
affect their own and their children’s health and
well-being.
5. All women must have the basic human right to control
their own fertility and reproductive health and plan
and space their pregnancies.
6. Pregnancy must be a voluntary choice.
7. Maternity is special and every society has an
obligation to make it safe. Safe motherhood is a basic
human right enshrined in UN statute.
8. All pregnant women must have access to antenatal/
prenatal, birth, and postnatal care as described by
WHO and other organizations.
9. All deliveries must be assisted by skilled birth
attendants.
10. All women must have access to quality life-saving
comprehensive emergency obstetric care if needed.
11. Care must be free or affordable. There should be no
bribes or “unofficial” fees.
12. All women should be treated with dignity, respect, and
compassion.
Modified from Fathalla M. Ten propositions for safe motherhood for all
women. From the Hubert de Watteville Memorial Lecture. Imagine a
world where motherhood is safe for all women—you can help make it
happen. Int J Gynaecol Obstet. 2011;72(3):207-213.
universal. Professor Mahmoud Fathalla once proposed ten steps
for safe motherhood, which have been updated and adapted for
this chapter.92 These are listed in Box 58-2, and if accepted by
the world’s leaders, policymakers, and influencers, the world
would be a far safer place for pregnant women and their unborn
children.
MAJOR OBSTETRIC COMPLICATIONS:
PREVENTION AND MANAGEMENT IN
RESOURCE-POOR COUNTRIES
The major complications of pregnancy are similar throughout
the world. The outcome for individual women depends upon
the care received and the capacity of the local health systems to
respond to their needs. Where comprehensive emergency obstet-
ric care is lacking, which includes staff and facilities for cesarean
delivery, severe morbidity or death results from prolonged
obstructed labor and/or fetal distress and life-threatening
hemorrhage.93
Postpartum Hemorrhage
The commonest cause of postpartum hemorrhage (PPH) is
uterine atony. As discussed in Chapter 18, the risk is highest in
mothers with multiple pregnancies, prolonged/obstructed labor,
preeclampsia/eclampsia, large uterine fibroids, and grand multi-
parity (five or more previous deliveries). In resource-poor set-
tings, intrapartum and postpartum hemorrhage continues to be
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1205
the leading cause of maternal mortality, accounting for 27% of
deaths.94
For many pregnant women already suffering from severe
chronic anemia due to malnutrition, micronutrient defi-
ciency, sickle cell disease, malaria, or helminthic infections,
even a blood loss of 500 mL at delivery can compromise their
already challenged hemodynamic state and can result in
hypovolemic shock. The prevention or early detection of bleed-
ing and the aggressive use of methods to reduce blood loss are
essential. However, blood products and storage facilities are
often unavailable,95 and in an emergency situation, when blood
is usually obtained from family members or donors, it is rarely
screened for infection and may be diluted with dirty water.
Uterine bimanual massage and uterotonic drugs, if available,
should be started at the first sign of atony. Compared with
placebo, prophylactic oxytocin decreases PPH greater than
500 mL and reduces the need for therapeutic uterotonics.96 It is
also associated with fewer side effects, specifically nausea and
vomiting, and evidence is limited to suggest that prophylactic
oxytocin is superior to ergot alkaloids for the routine prevention
of PPH. However, once an oxytocic agent has been given, oppor-
tunity is limited for further reduction in postpartum blood loss
with its use.97
Misoprostol, a synthetic prostaglandin E1 analogue, plays a
key role in the management of miscarriage.98 Unlike oxytocin,
it is low cost, stable at high temperatures, not degraded by
ultraviolet light, and can be used orally or rectally, which makes
it particularly useful in areas where skilled health care providers
and resources are less available. Recent studies indicate that
misoprostol distributed antenatally can be used accurately and
reliably by rural Ghanaian and Liberian women after delivery
and should be more widely implemented in other countries with
high home birth rates.99,100 Using Misoprostol for PPH preven-
tion appears acceptable to women, but community-based strate-
gies will be needed to increase distribution rates. However,
conventional injectable uterotonics are still preferable to either
intramuscular prostaglandins or misoprostol for the manage-
ment of the third stage of labor, especially for low-risk women.101
In cases of persistent PPH, aggressive measures to minimize
blood loss and secondary infection should be taken, but the
availability of facilities and skilled staff to perform balloon tam-
ponade and surgical compression sutures is limited. In facilities
unable to provide emergency care, low-technology compression
devices can help to stabilize a hemorrhaging mother long enough
for her to reach a hospital equipped to provide comprehensive
emergency services.34
Preeclampsia/Eclampsia
Hypertensive disorders of pregnancy account for 14% of
global maternal deaths28 and are the leading cause of death
in some urban areas in low-income countries.102 They fall
into four categories: (1) chronic hypertension, (2) gestational
hypertension or pregnancy-induced hypertension (PIH), (3)
preeclampsia/eclampsia, and (4) preeclampsia superimposed on
chronic hypertension (see Chapter 31).
Preeclampsia and eclampsia are associated with extremes of
maternal age (under 17 and over 35 years), nulliparity, multiple
pregnancies, preexisting hypertension, preeclampsia in a previ-
ous pregnancy, poor socioeconomic circumstances, and illiter-
acy.103,104 The increased susceptibility for indigenous African
women and blacks living in North America appears to be inde-
pendent of socioeconomic status and is likely due to biologic or
1206 Section VII  Legal and Ethical Issues in Perinatology
genetic factors.105,106 However, even in developed countries,
identifying women at risk can be difficult.107 Limited access to
antenatal care, little or no screening for high blood pressure and
proteinuria, and the wide variations in access to antihypertensive
drugs coupled with poor maternal understanding of the signs
and symptoms and the need to seek immediate care all help
explain the higher mortality from eclampsia in many low- to
middle-income countries. Severe morbidity increases eightfold
in women with preeclampsia, and it increases sixtyfold after an
eclamptic seizure,103 but the life-threatening neurologic compli-
cations and wider organ dysfunctions are reversible if adequate
treatment is started in time. Magnesium sulfate is the drug of
choice but is not available in many developing countries. A
recent systematic review of the use of magnesium sulfate in
low- and middle-income countries found that the majority
of women receive less than optimal dosages, usually due to
concerns about maternal safety and toxicity, cost, or available
resources.108
Training health care and community workers and raising
awareness in pregnant women about the signs and symptoms of
preeclampsia is essential. Recent evaluation of a clinical model
and algorithm in low-income countries has shown a reasonable
ability to identify women at increased risk of adverse maternal
outcomes associated with hypertensive disorders.103 Further-
more, a training intervention for health care providers to use an
evidence-based protocol for the treatment of preeclampsia and
eclampsia has been shown to be effective in reducing the associ-
ated case fatality rate.109
Sepsis
In the nineteenth and early twentieth century, puerperal sepsis
was the major cause of maternal death in industrialized coun-
tries; but improvements in hygiene and sanitation, together with
the introduction of antibiotics after the Second World War,
resulted in its rapid decline.110 Nevertheless, perinatal infection
still underlies 11% of maternal deaths and 33% of neonatal
deaths globally.28,111 Poverty contributes significantly to these
poor outcomes with clear evidence of an association between
poor sanitation, limited access to clean water, and maternal
death.112 Ignorance of both the causes and need to prevent
puerperal sepsis is widespread, and in some communities, people
still believe illness is due to evil spirits.113
For the 50% of women globally who deliver at home attended
only by a female relative or untrained traditional birth attendant
(TBA), infection is an ever-present danger. Harmful practices
are common, such as cutting the cord with broken glass and
dressing the stump with cow dung, and despite immunization
programs, neonatal tetanus is a frequent problem. Once infected,
mothers and babies often lack access to transport, and if they
reach a care facility, they frequently find that essential resources
such as antibiotics are unavailable.
The WHO guidelines on “the five cleans” needed during
delivery114 have led to the introduction of clean birth kits
that contain soap, plastic sheeting, gloves, sterile gauze, a
razor, and cord ties for use at home births.115 These simple
kits have achieved a relative reduction in neonatal mortality,
particularly in rural areas of developing countries.116 However,
wider interventions that included a skilled birth attendant in the
intervention were associated with a greater and more significant
reduction in neonatal mortality, omphalitis, and puerperal
sepsis.117 It is therefore considered best practice to provide safe
birth kits in the hands of skilled attendants.
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Human Immunodeficiency Virus and Malaria
Pregnant women infected with HIV and/or Plasmodium falci-
parum malaria suffer higher complication rates. The MMR for
HIV-infected women increases tenfold118 because their immu-
nodeficiency places them at greater risk of dying of pregnancy-
related sepsis. A recent review estimated the excess mortality
attributable to HIV among pregnant and postpartum women
to be 994 per 100,000 pregnant women.29
The maternal immune response to malaria is also altered
by pregnancy, and the most serious complications—including
cerebral malaria, hypoglycemia, pulmonary edema, and severe
hemolytic anemia—are more common. Approximately 40% of
the world’s pregnant women are exposed to malaria infection,
and primigravidae are more likely to develop severe maternal
anemia and to have low birthweight babies than multigravi-
dae.119 The fetal and perinatal loss may be as high as 60% to
70% in nonimmune women who contract malaria, and an addi-
tional 100,000 infant deaths in Africa result from malaria-
induced low birthweight in babies.120 Malaria infections among
pregnant women are less common outside Africa but are more
likely to cause severe disease, preterm births, and fetal loss. HIV
increases the risk of malaria and its adverse effects, and women
with both infections are at particular risk of adverse birth
outcomes.121
Obstructed Labor and Obstetric Fistula
Worldwide, obstructed labor occurs in an estimated 5% of
live births and accounts for 8% of maternal deaths.122 In sub-
Saharan Africa and parts of Asia, as many as 2 million young
women are affected and 50,000 to 100,000 new cases occur
every year.123,124 Obstructed labor, or “failure to progress,” with
or without fetal distress is the main indication for emergency
CD worldwide.125 The problem can be prevented by using a
partogram routinely in labor and by resorting to early operative
delivery when progress is slow. The partogram is a cheap, graphic
record of cervical dilation against time in labor; this simple
monitoring tool swiftly identifies when a labor is becoming
prolonged, thereby avoiding the development of obstetric fistu-
lae and death from a prolonged obstructed labor or a ruptured
uterus.126 Despite strong advocacy by the WHO and other
health care agencies, the global use of partograms is extremely
poor, and some senior clinicians wrongly assert that completing
the monitoring paperwork is unrealistic for already overworked
midwives and doctors.
Obstetric fistulae can occur at any age or parity but are most
common in first births, particularly in young girls with a poorly
developed pelvis. They are a direct consequence of prolonged
obstructed labor where the pressure of the impacted fetus leads
to the destruction of the vesicovaginal/rectovaginal septum with
subsequent loss of urinary and/or fecal control.127,128 They can
also be due to trauma at the time of pelvic surgery or as a result
of rape, and in parts of Africa, some 15% of cases are caused by
harmful female genital mutilation/cutting (FGM/C) before or
during labor by unskilled birth attendants.129 The tragedy is that
obstructed labor and obstetric fistulae are largely avoidable; a
summary of the preventive measures, as described by the WHO,
is shown in Table 58-4.
Obstetric fistulae are highly stigmatizing, and affected
women who constantly leak urine and fecal matter frequently
become social outcasts. Unlikely to have further children or
find employment, they are regarded as worthless to their families
and are frequently rejected. Specialist fistula repair centers and
 Chapter 58  Improving Global Maternal Health: Challenges and Opportunities
TABLE 58-4 PREVENTION OF OBSTETRIC FISTULAE
TYPE WHEN
Primary prevention Before pregnancy
Secondary prevention During pregnancy
Tertiary prevention During and after
delivery
Modified from Lewis G, de Bernis L. Obstetric Fistula: Guiding Principles for Clinical Management and Programme Development. Geneva: World Health Organization; 2006.
*Kenyan proverb.
CD, cesarean delivery.
the training of local surgeons to perform simple repairs helps to
restore function, fertility, and dignity to these women, but such
services are still beyond the reach of most fistula sufferers.
Cesarean Delivery
Cesarean delivery rates in many resource-poor countries remain
much lower than the 10% to 15% cited by the WHO as their
target in 1985.130 In other countries, the rate continues to rise
above unacceptably high levels, particularly in private hospi-
tals. In 2008, the WHO estimated an overall rate of 45.9%
for Brazil, 30.3% for the United States, and only 0.7% for
Burkina Faso; this equates to 3.18 million CDs that should
have been performed, and 6.20 million performed unneces-
sarily.35 The cost of the global “excess” of CD was estimated
to be $2.32 billion, whereas the cost of the global unmet need
for CD is a mere $432 million.35 This excess of CD is due to
maternal request, increasing maternal age, obesity, poor clinical
acumen, risk-averse behaviors, and fear of litigation.131 However,
it is not an operation without sequelae, and the rising incidence
of PPH due to placenta increta and/or placenta accreta involving
a previous CD scar has risen significantly, as demonstrated by
research, in the United Kingdom.132
As with all surgical procedures, the benefits and risks must be
carefully assessed for both mother and baby. A mother can die
of hypovolemic shock after a technically successful CD with
average blood loss if she is dehydrated, severely anemic, and
unable to cope with an operative insult. If the local health care
facility is poorly equipped with no access to emergency resuscita-
tion, blood transfusion, or anesthesia, it may be preferable to
delay the CD until transfer to a safer facility can be arranged.
However, significant delays in the second stage of labor leads to
additional complications that include increased likelihood of
hemorrhage, extension of the surgical incision into the vagina
or uterine arteries, sepsis, and fistula development.
PRACTICAL ADVICE ON VOLUNTEERING
TO WORK OVERSEAS
Many health professionals wish to “give back” to the most vul-
nerable of the world’s citizens; for some, offering their skills
in-country is becoming an increasingly popular option. Some
choose to work abroad to add experience to their curriculum
vitae or when applying for university or higher training, whereas
others wish to undertake research or practice their clinical skills.
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1207
WHAT
• Eliminate female genital mutilation, early marriage, and early childbearing
• Pregnancies are planned
• Skilled antenatal care
• During birth, awareness of signs and symptoms of impending fistula such as prolonged
labor and the need to seek care
• Manage prolonged labor (“Do not let the sun set twice on a laboring woman”*)
• Easy and early access to facilities equipped to manage essential obstetric care including CD
• Monitor every labor using partogram to identify women at risk or to monitor those who
develop obstructed labor and refer immediately if CD cannot be done in the current facility
• Use of indwelling catheters to help enable spontaneous closure of small fistulae in mothers
who have survived an obstructed labor
• Encourage such women to seek skilled care during next pregnancy and delivery
A growing trend is also to participate in teaching and/or bilateral
sustainable support programs in a needy facility organized by
their local institutions. Partnering among universities, hospi­
tals, and medical and midwifery schools is also becoming more
popular and is a good way to ensure a constant supply of teachers
and clinical staff upon which the host institution may have come
to rely. Volunteers also play a key role in “training the train-
ers”—that is, enabling cadres of local staff to act as ongoing
trainers in their own country. However, whatever the reasons,
volunteering only benefits the local population if the placement
is carefully planned, leads to sustainable improvement, and is
undertaken with care and understanding.
Well-organized trips conducted sensitively with respect for
the mothers, health care workers, and local cultures can be
life-enriching experiences for all concerned and yield life-
long benefits. However, this is not always the case; at its worst,
the arrogant, dismissive, or critical behavior of some volunteers
has given so called “volunteerism”133 a bad reputation locally.
Concern exists that such initiatives can lead to exploitation and
harm, particularly when projects are only focused on meeting
the volunteer’s needs or undertaking research that will not
benefit the local community. Indeed, in some parts of Africa,
what is now referred to as “extraction tourism”—in which only
the temporary visitor seems to benefit, often leaving a worse
situation and unpleasant feelings behind—is so bad that volun-
teers are no longer welcome.
For staff working within already well-established exchange
schemes, the knowledge of how to prepare and behave should
have already been explained, and initial local difficulties have
been overcome. However, for others working alone or with small
organizations, knowing what to expect and how to plan and
conduct the placement is the subject of this section.
In summary, the key personal qualities for working abroad
include:
1. Compassion and respect
2. Humility and honesty
3. High ethical and moral standards
4. Acceptance of the community and its values and a willing-
ness to behave in a culturally appropriate manner
5. Commitment to promote the welfare of the community you
serve first and putting their needs before your own
6. Ability to practice and teach the highest quality evidence-
based medicine using sustainable drugs and equipment
appropriate for the local circumstances, which will be
1208 Section VII  Legal and Ethical Issues in Perinatology
available after your departure and, in the case of machinery,
will include a source for spare parts so the equipment can
be repaired
7. An openness and willingness to learn from local staff, who
will have much to teach and share
8. A dedication to ensuring sustainability
9. The ability to resist being openly critical of the lack of
resources and poor infrastructure, saying how much better
things are at home (staff and patients are all too aware of
this)
10. The integrity to follow the same ethical principles you
would adhere to in your own institute or country (for
research, this is crucial)
Although these principles may seem glaringly obvious, experi-
ence has repeatedly shown that failure to follow such simple
guidelines can lead to disappointment and frustration on all
sides.
Respect
The health staff you will work with and the mothers, babies,
and communities you will care for are no different than any-
where else. Even though they may be poor beyond imagina-
tion, perhaps have inexplicable customs, and cannot speak
your language, each deserves as much respect as you would
give all your patients or colleagues at home. They are generally
living lives so hard as to be unfathomable, and this deserves
recognition, admiration, and compassion. Try to learn a few
words of their language, and treat everyone with dignity and
respect. Learn about social customs and taboos so you do not
inadvertently offend.
Realism
Do not have unrealistic expectations about what can be achieved
in the time available to you. In most countries, it takes far longer
to organize things, and wheels turn very slowly. Often, a lot of
bureaucratic red tape and delay intervenes both before leaving
and while in-country. Start organizing your trip months before-
hand, and obtain the necessary permissions before you leave.
Visas, too, can take time.
Remember that you will not be the first or last volunteer.
Volunteering is a growing business, and some popular facilities,
like the base camps of Mt. Everest, can become very over-
crowded. In some areas, numerous NGOs or other organizations
have been seen running the same type of program without joint
preplanning or teamwork. This lack of coordination is at best
ineffective, and at its worst, disastrous, because it leads to confu-
sion among volunteers and staff, duplication of work, and the
waste of very scarce resources. If you wish to work in a particular
place, always check who is working there already and contact
them. Check with the hosts to see if you would really be
welcome, and be sure they are not just being polite to a request
from someone they do not know. Rather than just trying to do
what you think will help, ask the local staff what would help fill
service gaps for them.
Also, be aware that health facilities are generally chronically
and completely understaffed with only one or two midwives or
doctors to care for numerous patients, at best. As such, they will
have little time to teach and nurture inexperienced volunteers
because they take up crucial time that could be spent with
patients. The paradox is that in wishing to please, they will be
polite and may spend too much time with you and not their
patients. Such volunteers would probably do better by joining
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an already well-established program that can accommodate
and acclimatize them. Some larger programs hold predeparture
training workshops. In these sessions, be honest about your skills
and abilities, and consider how much supervision you would
need; then choose your options carefully. You may be welcome,
but you will need to be able to step in immediately and pull
your own weight rather than becoming an additional burden on
an already overstretched staff.
Health Care Staff
The staff you will work with invariably will work longer hours,
in far worse conditions, and for far less pay than you. Sometimes
they work with no pay at all if money in the health center is
limited for a while. In addition, they are rightly proud of what
they can achieve with so very little. Although everyone is almost
always polite, talking about your own salary or showing large
amounts of money is insensitive. However initially surprised or
shocked you may be, do not be critical of the facility, lack of
resources, or age or type of equipment available. The staff will
already be acutely aware of the limitations and will be proud of
the innovative local solutions they may have devised to the best
of their resources and ability. Although they will have been
trained in a variety of institutions, with different knowledge and
skills, they will most certainly be more able than you to under-
take more complex operations under challenging conditions
until you, too, have become expert in their art. Examples of this
could include complex fistula repair or even the simple repairs
done by the trained former patients of the Addis Ababa Fistula
Hospital.
Midwives are the backbone of most maternity services
around the world and are widely respected and generally
highly competent. Do not underestimate their abilities. They
are specialists in “normal” deliveries, and in many places, includ-
ing the United Kingdom, they teach medical students and junior
residents crucial obstetric skills. In European countries, some
work as independent autonomous practitioners. In the United
Kingdom, midwives are present at every birth, and over 65% of
women are delivered with their assistance alone. Either indepen-
dently or working within a multidisciplinary team for higher
risk pregnancies, their skills help improve maternal health care;
the latest direct-cause maternal mortality ratio for the United
Kingdom, 5.4 per 100,00 live births, is one of the lowest in the
world.30 Other countries with very low death rates are also char-
acterized by the inclusion of their own midwives. They are highly
skilled in managing the normal and knowing when to refer for
help; the maternal mortality rates in these countries are the
lowest in the world. Experienced midwives who work in
resource-poor countries will have seen and managed more sick
women than most obstetricians in a lifetime. They work without
the resources taken for granted elsewhere. A number have a wide
variety of other skills, and in certain places—with training, for
example—they even undertake cesarean delivery, symphysiot-
omy, and simple fistulae repair. However, there are far too few
midwives, and they are often vastly overworked with intolerably
high caseloads and very long shifts. One midwife in a labor ward
with 50 or more women is not unusual. Some adopt the babies
of mothers who have died, and most are pillars of their com-
munity. All will have much to teach you.
In many low-income countries, only a few specialists in
obstetrics and gynecology work in the public sector; other health
care professionals such as family doctors, medical or clinical
officers, or operating theater assistants are trained to perform
 Chapter 58  Improving Global Maternal Health: Challenges and Opportunities
many routine procedures. In obstetrics, this involves training
staff in the competencies to undertake some work traditionally
done by maternity health care professionals, doctors, midwives,
and nurses—so-called task shifting.134 To meet the crisis in
human resources all across the developing world, low- and
mid-level workers are expanding their skills and taking on
new roles according to the competencies in which they have
been trained and are able to master.
Research
Visitors who plan research activities in a foreign country must
only undertake these having first obtained national and local
ethics committee approval. This can take months, and the
process will vary according to local laws. Additionally, the rules
in their own institution and country must be followed. If
required, consent forms should be obtained from all study par-
ticipants, having first clearly explained the process in their own
language. If a research project is performed in a country with
no ethics committee or institutional review board or similar
body, researchers should ensure their proposed study adheres to
the World Medical Association Declaration of Helsinki.135
Research projects should also only focus on interventions that
could benefit the women, babies, or communities under consid-
eration. It is not moral or ethical to test drugs, equipment,
supplements, vaccines, and so on that will be so expensive as to
be unavailable to the women who were the research subjects.
Because of their punishing workload, health care staff in low-
income countries have little or no time to prepare papers for
publication. However, local researchers should be encouraged
and helped to write and author papers, be first author where
appropriate, and present their findings at local and international
conferences. This not only recognizes their contribution and
benefits their careers, it also adds to their knowledge base; such
local experience is invaluable when planning appropriate and
effective interventions. This support for local doctors is becom-
ing an increasing requirement of those who fund medical and
other research programs.
Predeparture Preparation
The following list, although not exhaustive by any means, should
help you to start your preparation. Although some general
pointers are always helpful, issues specific to the location may
apply that you will need to identify and understand. Your hosts
can help you in this, but remember: you are ultimately respon-
sible for your health and well-being while in a volunteering
program.
Thoroughly research the country and institutions you are
planning to visit well in advance of leaving. Apart from general
background, read any WHO, UN, World Bank, and other
institutions’ in-country fact sheets on the general health of
the population as well as in your specific area. Talk with
ex-volunteers and find out their practical tips.
Try to arrange an orientation session about your placement.
If it is with a large organization, they may invite you to attend
a predeparture meeting to discuss practicalities and your respon-
sibilities. If they are abroad, social media such as Skype are
extremely helpful.
Learn about requirements for local medical registration and
arrangements for medical indemnity. Ask for their safety briefing
packs, and obtain key contact numbers.
Ensure that your passport is valid for at least 6 months beyond
the intended length of your entire stay, including any vacation
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1209
time at the end. Check visa requirements well in advance of your
departure by contacting the Embassy or High Commission for
the country you are visiting. This may take a long time to
complete.
Evaluate your budget. If not provided for you, the cost of
subsistence is usually very low, but the cost of accommodation
may vary widely. Ask your hosts for their recommendations.
Factor in costs for a comprehensive package of personal insur-
ance for health, travel, and loss of possessions.
Consult an established travel center concerning vaccinations
and malaria prophylaxis at least 6 months before you travel.
Some vaccines, such as against yellow fever, are compulsory to
enter many sub-Saharan African countries. The availability of
postexposure prophylaxis for HIV is essential in many countries,
and you may need to take these supplies with you. Also arrange
to take supplies of any essential drugs you personally need
because they are unlikely to be widely available elsewhere. You
may need to bring these into the country with a letter or con-
firmatory prescription from your physician.
Contact your licensing body for advice on maintaining your
medical licensure and indemnity at home during your place-
ment. Allow yourself maximum time to gain medical registra-
tion within the country you are visiting because this can be time
consuming.
You will need to protect your pension and take precautions
for every eventuality. Research the best options for life insurance.
You will also wish to consider whether you will be taking any
drugs or equipment with you and, if so, be sure that you are not
at risk of contravening local customs and excise regulations and
such. You should check this with your sponsor and on the rel-
evant Web sites.
It is beneficial to arrange for two mentors, one in-country and
one at home, to support you. Ask your sponsors to arrange an
in-country mentor. Your hospital, professional association, or
medical school may be able to put you in touch with colleagues
who have experience working in the country and who may be
prepared to mentor to you while you are away.
As soon as you arrive, it is essential that you register with the
embassy or foreign office of your home country so that they are
aware that you are there should there be any emergencies. Many
of these organizations use Twitter or other social media to give
regular updates of the current political and security climate.
Maintain regular contact with your organizing institution and
with your mentors.
Keep a diary, take photographs (with permission), and also
relax, have fun, make new friends, and enjoy your new
environment.
KEY POINTS
◆ Every day, 800 women die as a result of pregnancy or
childbirth, and an additional 16,000 develop severe and
long-lasting complications.
◆ Every day, 8000 newborn babies die and 7000 are still-
born, and more than half of these deaths are from
maternal complications.
◆ Adolescent pregnancies account for 11% of all births
worldwide, and these young girls and their babies are at
far higher risk of death and complications than other
mothers.
1210 Section VII  Legal and Ethical Issues in Perinatology
◆ Of all the maternal and neonatal deaths worldwide,
99% take place in developing countries.
◆ The leading obstetric causes of maternal death in devel-
oping countries are hemorrhage, puerperal sepsis,
preeclampsia, unsafe abortion, obstructed labor, and
embolism. HIV causes a growing number of deaths in
countries where it is endemic.
◆ If all pregnant women and their babies could access the
maternity care recommended by the WHO, the annual
number of maternal deaths would fall by two thirds—
from 290,000 to 96,000—and newborn deaths would
fall by more than three quarters to 660,000 each year.
◆ If all women had control over their fertility and could
access effective contraception, unintended pregnancies
would drop by 70%, and unsafe abortions would drop
by 74%.
◆ Apart from a lack of skilled health care and other
resources, the quality of the care provided also varies
widely. The clinical guidelines and protocols set forth
by the WHO and professional organizations need to be
urgently implemented, and their uptake audited, in
developed as well as in developing countries.
◆ Safe motherhood for all women is enshrined as a basic
human right by the United Nations, yet many societies
have yet to recognize and address this, and they fail to
provide the necessary resources to provide adequate
reproductive health, maternity, and newborn care or to
enact and enforce laws to support equality for women
in all aspects of their life, which includes abolition of
child marriage and other harmful traditional practices.
◆ A woman’s life is always worth saving.
Acknowledgment
The section on the United States was written with assistance by
William Callaghan, MD, MPH, chief of Maternal and Infant
Health Branch, Division of Reproductive Health, Centers for
Disease Control and Prevention, and in collaboration with the
American College of Obstetricians and Gynecologists.
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1. Singh S, Darroch JE, Ashford LS. Adding It Up: Costs and Benefits of
Investing in Sexual and Reproductive Health. New York: Guttmacher Insti-
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3. Hardes K, Gay J, Blanc A. Maternal morbidity: neglected dimension of
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4. United Nations Children’s Fund. The Progress of the Nations. 2001. New
York: UNICEF; 2001.
5. Islam K, Gurdtham UG. A systematic review of the estimates of costs-illness
associated with maternal and new-born ill-health. Part of the World Health
Organisation Maternal-Newborn Health and Poverty series. Geneva: WHO.;
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Estimates by WHO, UNICEF, UNFPA, The World Bank and the United
Nations Population Division Report 2014. Geneva: WHO; 2015.
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2009;374:881-892.
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