Elsevier

The Lancet

Volume 388, Issue 10056, 29 October–4 November 2016, Pages 2164-2175
The Lancet

Series
Diversity and divergence: the dynamic burden of poor maternal health

https://doi.org/10.1016/S0140-6736(16)31533-1Get rights and content

Summary

Maternal health is a big issue and is central to sustainable development. Each year, about 210 million women become pregnant and about 140 million newborn babies are delivered—the sheer scale of maternal health alone makes maternal well being and survival vital concerns. In this Series paper, we adopt primarily a numerical lens to illuminate patterns and trends in outcomes, but recognise that understanding of poor maternal health also warrants other perspectives, such as human rights. Our use of the best available evidence highlights the dynamic burden of maternal health problems. Increased diversity in the magnitude and causes of maternal mortality and morbidity between and within populations presents a major challenge to policies and programmes aiming to match varying needs with diverse types of care across different settings. This diversity, in turn, contributes to a widening gap or differences in levels of maternal mortality, seen most acutely in vulnerable populations, predominantly in sub-Saharan Africa. Strong political and technical commitment to improve equity-sensitive information systems is required to monitor the gap in maternal mortality, and robust research is needed to elucidate major interactions between the broad range of health problems. Diversity and divergence are defining characteristics of poor maternal health in the 21st century. Progress on this issue will be an ultimate judge of sustainable development.

Introduction

Around 210 million women become pregnant annually, meaning that maternal health is not a marginal issue.1, 2 Maternal health is key to sustainable development and to future generations. Poor maternal health as measured by mortality and morbidity, however, remains an issue for marginalised women—those women who are vulnerable by virtue of where they live or who they are. As the world moves from Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs), patchy progress across regions and countries has been achieved in the reduction of maternal mortality. High mortality continues in some populations, presenting a major challenge to one of the strategic cornerstones of the SDG agenda—reducing inequities—“leaving no one behind”.3 In 1876, William Farr commented on maternal death as “A deep, dark continuous stream of mortality” and asked “how long is this sacrifice to continue?”.4 Drastic reductions in maternal mortality—ending the sacrifice to which William Farr refers—are realistic, and have already been achieved in some countries and for some women. The challenge to replicate this success for all populations by 2030 is complex but not insurmountable. In this Series paper, we examine two important contributors to the challenge: first, the increasing diversity in the magnitude and causes of maternal mortality and morbidity and, second, the widening inequities or divergence in these key indicators, between countries and within populations. This diversity and divergence emphasises the dynamic nature of the burden of maternal mortality and morbidity and hence the key need for dynamic health systems. We aim to use the best available evidence to further illuminate the changing burden and so provide insights for the new strategic frameworks for action in the SDG era.5, 6

Key messages

  • Pregnancy and childbirth affects the lives of millions of women and families worldwide each year. At this scale, sustainable development goal (SDG) 3 will not be achieved without reducing the burden of poor maternal health in all populations.

  • Progress has been made in reducing maternal mortality globally, but this is patchy at regional and national levels—the hard-won gains over the last 25 years in some countries are susceptible to slow down.

  • The causes of maternal mortality and morbidity are increasingly diverse, including a shift in the contribution of non-communicable diseases, reflecting large-scale demographic, epidemiological, socioeconomic, and environmental transitions.

  • This diversity of burden has major implications for the crucial policy and programmatic goal of matching needs with care. Diverse maternal health needs require diverse maternity services, within the framework of universal health coverage.

  • At the dawn of the SDG era, the distribution of poor maternal health is highly inequitable between and within populations; the gap between the group of countries with the lowest and highest maternal mortality increased from around 100 times to 200 times difference between 1990 and 2013.

  • The highest burden of maternal mortality and severe morbidity clusters where health systems are weakest and where the broader context is challenging, such as in fragile states.

  • In all countries, the burden falls disproportionately on the most vulnerable groups of women. This reality presents a challenge both to the rapid catch-up required to achieve grand convergence and to the underlying aim of the SDGs—“to leave no one behind”.

  • Reliable population-based data on poor maternal health, disaggregated by key indicators of vulnerability, are essential to monitor widening inequities, and to inform innovative policies and programmes to halt this divergence and to manage the increasing diversity of burden..

This paper is the first in the 2016 Lancet Series on maternal health. It focuses on creating the overall picture and thus relies heavily on aggregate evidence, which enables large-scale regional and international comparisons. Both the United Nations' Maternal Mortality Estimation Inter-agency Group (MMEIG)7 and the Global Burden of Disease (GBD)8 study estimated maternal health parameters at global, regional, and national levels, and used different but overlapping data inputs, data adjustments, and modelling methods. In this Series paper, we did not aim to compare and cross-validate different estimates, something that other papers have undertaken.9, 10, 11 Instead, we pluralistically use both UN and GBD sources, drawing on each depending on the degree of temporal or regional specificity the sources provide, along with other data to produce the most appropriately disaggregated statement of the burden of poor maternal health. We acknowledge that useful insights can also be obtained from large-scale studies and datasets from individual countries. Our focus, however, is on lessons across major world regions, and specifically for low-income and middle-income countries (LMICs) where levels of fertility (the primary exposure) and maternal death (the most adverse outcome of pregnancy-related health problems) are highest. This macro-level focus is inevitably limited by the availability of relevant data. We used three main approaches to creatively fill the gaps: our own review of systematic reviews12, 13 on a broad range of the morbidities identified by WHO;14, 15 a structured review of papers with international comparative analyses and grey literature published since 2005; and secondary analyses of large-scale international data series available in the public domain.

Section snippets

Acknowledgment of diversity in the burden of poor maternal health

As the MDG era ended, almost half of the world's estimated population of 7·3 billion were female, about 52% of whom were aged 15–49 years, and a further 5% were girls aged 12–14 years.1 With an estimated 210 million pregnancies and 140 million livebirths annually, the sheer scale of these numbers cannot be ignored.1, 2 Ensuring the good health of women and newborns during and after pregnancy, as well as prevention of unintended pregnancies, has enormous implications for health systems. Thus

Maternal mortality

The number of maternal deaths globally has fallen continuously since 1990. The UN7 estimates 303 000 maternal deaths occurred worldwide in 2015. This estimate corresponds to a fall in the maternal mortality ratio of 44% over 25 years (table 1). Such a decline is substantial in view of the number of women entering the reproductive period and the number of pregnancies and livebirths over the same time frame has steadily increased. The decrease in the death numerator and the increase in the

Divergence in the burden of poor maternal health

Acknowledgment that poor maternal health is unevenly distributed is important so that programmatic efforts can be prioritised and progress can be judged. The way burden clusters is a reminder of the social determinants of health,18 reflecting inequities in wealth, rights, and access to care. Improvements in average levels of maternal health problems can mask increases in relative and absolute inequities between and within populations. This disparity is acknowledged in the strategic frameworks

Conclusion

The burden of maternal mortality and morbidity is dynamic, with shifts in the magnitude, causes, and distribution over time. The outcomes and care experiences of the estimated 210 million women who were pregnant in 2015 were different from those at the turn of the millennium. Further differences will be apparent for women who experience pregnancy at the end of the SDG period in 2030. Changes in health status suggest considerable gains have been achieved for the world's population overall.

References (97)

  • N Watts et al.

    Health and climate change: policy responses to protect public health

    Lancet

    (2015)
  • N Oomman et al.

    Modernising vital registration systems: why now?

    Lancet

    (2013)
  • L Say et al.

    Global causes of maternal death: a WHO systematic analysis

    Lancet Glob Health

    (2014)
  • C AbouZahr et al.

    Civil registration and vital statistics: progress in the data revolution for counting and accountability

    Lancet

    (2015)
  • P Byass

    Uncounted causes of death

    Lancet

    (2016)
  • B Zaba et al.

    Effect of HIV infection on pregnancy-related mortality in sub-Saharan Africa: secondary analyses of pooled community-based data from the network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA)

    Lancet

    (2013)
  • G Sedgh et al.

    Induced abortion: incidence and trends worldwide from 1995 to 2008

    Lancet

    (2012)
  • CJL Murray et al.

    Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition

    Lancet

    (2015)
  • L Say et al.

    Maternal near miss – towards a standard tool for monitoring quality of maternal health care

    Best Pract Res Clin Obstet Gynaecol

    (2009)
  • V Filippi et al.

    Health of women after severe obstetric complications in Burkina Faso: a longitudinal study

    Lancet

    (2007)
  • KS Khan et al.

    WHO analysis of causes of maternal death: a systematic review

    Lancet

    (2006)
  • M Prince et al.

    No health without mental health

    Lancet

    (2007)
  • MN Norhayati et al.

    Magnitude and risk factors for postpartum symptoms: a literature review

    J Affect Disord

    (2015)
  • SA Rasmussen et al.

    Maternal obesity and risk of neural tube defects: a metaanalysis

    Am J Obstet Gynecol

    (2008)
  • MA Faucher et al.

    Gestational weight gain in obese women by class of obesity and select maternal/newborn outcomes: A systematic review

    Women Birth

    (2015)
  • DT Jamison et al.

    Global health 2035: a world converging within a generation

    Lancet

    (2013)
  • P Byass

    A transition towards a healthier global population?

    Lancet

    (2015)
  • P Piot et al.

    Defeating AIDS-advancing global health

    Lancet

    (2015)
  • SS Lim et al.

    A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010

    Lancet

    (2012)
  • N Walker et al.

    Patterns in coverage of maternal, newborn, and child health interventions: projections of neonatal and under-5 mortality to 2035

    Lancet

    (2013)
  • WJ Graham et al.

    The familial technique for linking maternal death with poverty

    Lancet

    (2004)
  • WJ Graham et al.

    Counting what counts for maternal mortality

    Lancet

    (2014)
  • CG Victora et al.

    How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys

    Lancet

    (2012)
  • LP Freedman et al.

    Disrespect and abuse of women in childbirth: challenging the global quality and accountability agendas

    Lancet

    (2014)
  • World Population Prospects: The 2015 Revision, Key Findings and Advance Tables

  • S Singh et al.

    Adding it up: the costs and benefits of investing in sexual and reproductive health 2014

    (2014)
  • The road to dignity by 2030: ending poverty, transforming all lives and protecting the planet. Synthesis report of the secretary-general on the post-2015 agenda

    (2014)
  • A Oakley

    The captured womb: a history of the medical care of pregnant women

    (1984)
  • M Temmerman et al.

    Towards a new Global Strategy for Women's, Children's and Adolescents' Health

    BMJ

    (2015)
  • D Chou et al.

    Ending preventable maternal and newborn mortality and stillbirths

    BMJ

    (2015)
  • RE Dorrington et al.

    Acknowledging uncertainty about maternal mortality estimates

    Bull World Health Organ

    (2016)
  • V Smith et al.

    Methodology in conducting a systematic review of systematic reviews of healthcare interventions

    BMC Med Res Methodol

    (2011)
  • DF Stroup et al.

    Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group

    JAMA

    (2000)
  • T Firoz et al.

    Measuring maternal health: focus on maternal morbidity

    Bull World Health Organ

    (2013)
  • D Chou et al.

    Constructing maternal morbidity—towards a standard tool to measure and monitor maternal health beyond mortality

    BMC Pregnancy Childbirth

    (2016)
  • Strategies toward ending preventable maternal mortality (EPMM)

    (2015)
  • Global Sustainable Development Report 2015 Edition

    (2015)
  • Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health

    (2008)
  • Cited by (196)

    View all citing articles on Scopus
    View full text