The truth about childbirth and death

Carolyn Moynihan
Aug 07, 2014
Reproduced with Permission

The death of a mother is a special kind of tragedy, and the persistence of high rates of maternal mortality in some parts of the world is a global disgrace, given that most of it could be prevented by basic health care. Collectively, maternal deaths are the chief indicator of the health of the world's mothers and the reduction of these deaths is a key aim of international health and development organisations.

The fifth of the United Nations' current Millennium Development Goals , for instance, is to reduce the maternal mortality ratio by 75 percent by 2015, when a new set of goals is likely to be adopted. But, a year away from this deadline, reports show ratios as high as 1000 maternal deaths for every 100,000 live births in parts of the developing world, and the World Health Organisation records a global reduction of only 45 percent since 1990.

But how accurate are the figures for maternal mortality? No-one wants to under-estimate how many mothers are dying from lack of care in pregnancy and childbirth, but over-estimates would not be helpful either, and actual figures are to be preferred wherever they are available.

Such figures are in fact available in a number of countries, although estimates arrived at by mathematical modelling continue to be published in global surveys.

A study published in the British journal, Public Health , earlier this year and led by researchers at the MELISA Institute in Chile, compared maternal mortality ratios in three global reports with figures obtained from official data from eight countries with reliable vital statistics in the Americas, including the United States, Mexico and Chile.

The research reveals that two recent reports show discrepancies between 14 percent and 100 percent when compared with official maternal mortality figures from the countries evaluated.

In the case of Chile, for example, official records showed an MMR of 16.5 deaths per 100,000 live births, while a study led by Saifuddin Ahmed produced an MMR of 27 (+64 percent) and WHO reported 26 (+58 percent). For Mexico the official data showed an MMR of 42 compared with Ahmed's 62 (+46 percent) and WHO's 85 - double the actual rate!

In contrast, a third independent report, conducted by researchers from the Institute for Health Metrics and Evaluation (IHME), University of Washington, and published in The Lancet was considerably more accurate. Their estimate for Chile was 21 (+27 percent) and for Mexico 52 (+23 percent).

What made the difference? Elard Koch, lead author of the new MELISA Institute study, says that the IHME study included a variable missing from the more recent studies - the educational level of the mothers - and this "apparently increased the accuracy of the estimates."

MELISA's own research, says Koch, shows that "women's education level is not only a strong predictor of overall mortality, but particularly of maternal mortality." A recent study the institute conducted in Chile identified the level of female education as a main determinant of the progress in maternal health for the past 50 years, with synergistic effects on other variables such as access to prenatal care, fertility rate, and childbirth delivery by skilled personnel.

Koch notes: "To obtain more accurate ratios we suggest that researchers use official data from countries with reliable records, and, according to the latest maternal mortality report drafted by the UN in 2013, such countries now number 67. If reliable records are unavailable, estimation models considering women's education level should be preferred."

Data from 67 countries should keep quite a few researchers busy over the coming years, if accuracy is their main concern.

Muddying the waters is the view of many global health experts that the most efficient way to reduce maternal deaths is to prevent births , if not by contraception then by abortion. They assume that laws prohibiting or restricting abortion in many developing countries (including most of Latin America) lead to "unsafe abortions" and contribute significantly to maternal mortality. The higher the MMR in such countries the stronger this argument seems to be.

However, MELISA's Chile study, a rigorous one that specifically investigated the effect of a government ban on abortion in 1989 after years when it was legal, showed that the law change had no effect on abortion hospitalisations, which continued a decades-long decline. In fact, today, with abortion still illegal (though the President wants that to change ) Chile has one of the lowest abortion-related maternal death rates in the world, with a 92 percent decline since 1989 and nearly 100 percent decline over 50 years.

If the global community really wants to make motherhood safe for all women, the research pioneered by the MELISA institute shows the issues that need to be prioritised: access to prenatal care, skilled birth attendants and, critically, the education of women - and not just education about birth control.

A mother who is able to take advantage of knowledge about hygiene and nutrition, who realises the benefits of education for her children and is aware of any opportunities available to improve her family's standard of living, is in a better position, together with her husband, to make decisions about fertility.

If she then wants to use contraceptive pills or devices or even have an abortion - the negative effects of which, not excluding death, she should also be informed about - it is up to her. To offer her those things before she is able to read, or get basic obstetric care when she needs it, is to use her as a means to an end. Even if the end is to lower total maternal mortality, it is not justified.