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Few signs of improvement in maternal health
Pregnancy and childbirth and their consequences are still the leading causes of death, disease and disability among women of reproductive age in developing countries - more than any other single health problem. Over 300 million women in the developing world currently suffer from short-term or long-term illness brought about by pregnancy and childbirth; 529 000 die each year (including 68 000 as a result of an unsafe abortion), leaving behind children who are more likely to die because they are motherless ( 59 ).
There have been few signs of global improvement in this situation. However, during the 1960s and 1970s, some countries did reduce their maternal mortality by half over a period of 10 years or less. A few countries such as Bolivia and Egypt have managed this in more recent years. Other countries appear to have suffered reversals (see Box 1.3). Recent success stories in maternal health are less often heard than those for child health. This is partly because it takes longer to show results, partly because changes in maternal mortality are much more difficult to measure with the sources of information available at present.
Today, predictably, most maternal deaths occur in the poorest countries. These deaths are most numerous in Africa and Asia. Less than 1% of deaths occur in high-income countries. Maternal mortality is highest by far in sub-Saharan Africa, where the lifetime risk of maternal death is 1 in 16, compared with 1 in 2800 in rich countries.
Information on maternal mortality remains a serious problem. In the late 1970s, less than one developing country in three was able to provide data - and these were usually only partial hospital statistics. The situation has now improved but births and deaths in developing countries are often only registered for small portions of the population except in some Asian and Latin American countries. Cause of death is routinely reported for only 100 countries of the world, covering one third of the world’s population. It is even difficult to obtain reliable survey data that are nationally representative. For 62 developing countries, including most of those with very high levels of mortality, the only existing estimates are based on statistical modelling. These are even more hazardous to interpret than those from surveys or partial death registration. The countries that rely on these modelled estimates represent 27% of the world’s births. Effectively, this leaves no record of the fate of 36 million - about 1 out of 4 - of the women who give birth every year.
Gradual improvements in data availability, however, mean that a growing database now exists of maternal mortality by country. Since 1990, a joint working group of WHO, the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA) has been regularly assessing and synthesizing the available information ( 60 ). It has not been possible, though, to assess changes over time with any confidence: the uncertainty associated with maternal mortality estimates makes it difficult to say whether that mortality has gone up or down, so no global downturn in maternal mortality ratios can yet be asserted.
Nevertheless, there is a sense of progress, backed by the tracking of indicators that point to significant increases in the uptake of care during pregnancy and childbirth in all regions except sub-Saharan Africa during the 1990s. The proportion of births assisted by a skilled attendant rose by 24% during the 1990s, caesarean sections tripled and antenatal care use rose by 21%. Since professional care is known to be crucial in averting maternal deaths as well as in improving maternal health, maternal mortality ratios are likely to be declining everywhere except for those countries which started the 1990s at high levels. For these, which are mainly in sub-Saharan Africa, there has been no sign of progress.
59 Katz J, West KP Jr., Khatry SK, Christian P, LeClerq SC, Pradhan EK et al. Risk factors for early infant mortality in Sarlahi district, Nepal. Bulletin of the World Health Organization, 2003, 81:717-725.
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