Why does childbirth still kill?

Each year, more than 5.6 million women and newborns around the world die during pregnancy, childbirth, or in the first month of life. What is more shocking is that the vast majority of these deaths should never happen. Since 1990, maternal deaths have decreased by 44 per cent and the rate of newborn deaths has fallen as well, though more slowly. Still, 99 per cent of maternal deaths and 80 per cent of newborn deaths can be prevented with known interventions.

We know that giving birth in a health facility with a skilled clinician should mean better care and better outcomes. In many places, however, encouraging women to deliver in health facilities rather than at home has not resulted in reduced mortality. The problem is low-quality care. To make progress on reducing mortality, we now need to focus on improving and strengthening the frontline primary-care facilities where the majority of births worldwide are happening.

For the last three years, we ran one of the world’s largest maternal-newborn health trials in the Indian state of Uttar Pradesh, to see if we could reduce deaths by improving the quality of care in frontline facilities. These facilities had on average 1,200 deliveries per year, or 3-4 per day. Before the intervention started, less than 1 per cent of staff washed their hands prior to delivery. Only 25 per cent of women received the right medications to prevent post-partum bleeding. Overall adherence to standard practices was 40 per cent.

Using bedside peer-coaching of birth attendants and facility managers, along with the WHO Safe Childbirth Checklist, we focused on the basics: hand washing to prevent infection, monitoring and treatment of women’s blood pressure to prevent eclampsia, uterine massage and appropriate medication to prevent hemorrhages. We saw marked improvement in care. Birth attendants completed 70 per cent of the known life-saving steps during childbirth.

Yet it was not enough. We saw no reduction in mortality rates.

We knew that in order to impact maternal and newborn mortality, we had to address the whole health system. Effective systems must be able to address all gaps in care, including gaps in supplies and equipment, skills and capabilities, the relationships between clinical leaders and frontline providers and the relationships between providers and the families they serve. These relationships must be based on respect and trust. This is true everywhere in the world.

However, in the rural clinics in this part of the world, coaching leaders and teams in using a checklist solved some of these problems but not enough of them. We are closer than we have ever been to closing the gap on maternal and newborn mortality. We know what is needed to make childbirth safer.

Now we must determine how to make that happen in every facility around the world. 

It is time we deliver for women and their newborns.

Katherine Semrau, assistant professor of medicine at Harvard Medical School and Associate Epidemiologist at the Brigham and Women’s Hospital in the Division of Global Health Equity, is director of the Ariadne Labs BetterBirth Programme. Copyright: Project Syndicate, 2018.
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