Women are still deprived of access to lifesaving essential and emergency obstetric care

1. Background 

The global community came together 20 years ago in Nairobi, Kenya, to launch the Safe Motherhood Initiative and highlight the shameful situation of maternal health and survival—the most striking inequity in public health. This global initiative was launched to generate political will, identify effective interventions, and to mobilize resources that would rectify a horrifying injustice and violation of women's right to life. Yet, each year 3.3 million babies are stillborn and more than 4 million newborns die within 28 days of coming into the world. There are 536000, often sudden, unpredicted deaths of women during pregnancy, during childbirth, or after the baby has been born—leaving behind devastated families, often pushed into poverty because of the cost of health care that came too late or was ineffective.

The international community agreed to address the issue of maternal mortality by agreeing to Millennium Development Goal 5, to improve maternal health, with one of its boldest targets the reduction of the maternal mortality ratio (MMR) by three quarters between 1990 and 2015 [1]. However, maternal and newborn mortalities remain the world's most neglected problems, and progress on reducing the maternal mortality ratio and newborn mortality remains very uneven and continues to stagnate in countries where the problems are most acute. At the present rate of progress, the world will fall well short of the target for reduction of maternal mortality as well as infant mortality.

2. Situation analysis 

In high-income countries maternal deaths from obstructed labor are nonexistent, and universal access to simple and effective interventions to prevent and treat postpartum hemorrhage, sepsis, and hypertensive disorders of pregnancy has been ensured for many years. In low-income countries a third of all pregnant women receive no health care during pregnancy, 60% of deliveries take place outside health facilities, and only about 60% of all deliveries are attended by skilled staff. As long as effective strategies to increase attendance of skilled personnel at childbirth, provide timely lifesaving emergency obstetric care, and promote facility-based deliveries are not implemented at scale and with quality, it will be difficult to reduce maternal mortality and morbidity [2].

In some regions of the world, primarily in Sub-Saharan Africa and South Asia, women are still facing very high risks of dying during pregnancy and childbirth. This situation is an infringement of their rights. Article 12.2 of the Convention on the Elimination of All Forms of Discrimination against Women, which 185 countries have ratified to date, requires States Parties: “…ensure to women appropriate services in connection with pregnancy, confinement and the post-natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation” [3]. The causes of maternal mortality and morbidity are so clear, and effective interventions to combat them are well known—it is therefore difficult to avoid the conclusion that they have remained unaddressed for so long because of women's disadvantaged social, political, and economic status in many societies.

There is no ambiguity about why most of these women are dying. As identified by WHO 20 years ago, women are dying because they have no or limited access to health services, or because the quality of care is poor during pregnancy, childbirth, and in the postpartum and postnatal period, and when life-threatening complications arise [4]. They die because of hemorrhage, sepsis, hypertensive disorders, unsafe abortion, and prolonged or obstructed labor—complications that are unpredictable, but that can often be effectively managed in a responsive and functional health system that provides quality skilled care during pregnancy, childbirth, and the postpartum and postnatal periods, and can handle emergencies when they occur [5]. Yet thousands of women are deprived of this opportunity to have timely access to quality skilled care, including emergency care services. Poverty, inequity, women's low status, and societal attitudes toward women and their needs are still the underlying factors affecting women's access to healthcare services [6].

We also know that most maternal deaths occur during childbirth or the first 24 hours post partum, and most complications can not be predicted or prevented. Individual complications are quite rare, and timely diagnosis and appropriate interventions require considerable skills to prevent deaths and to avoid introducing further complications and harm. The location of women when they start labor and then deliver, who is attending them, and how quickly they can be transported to referral-level care are thus crucial factors determining access to interventions that are needed and feasible [7]. Two cost-effectiveness analyses of maternal and neonatal care packages and means of distribution have emphasized the potential of close-to-client care for normal and complicated cases—essentially encompassing basic essential obstetric care and emergency obstetric care, and finding them among the most cost-effective options [8], [9]. The unpredictability, suddenness, and the short window of opportunity to save lives on the one hand, and the cost -effectiveness, organizational, and managerial feasibility of having a team of skilled workers in one place on the other hand provide us with a strong rationale to promote and provide the choice and means to all pregnant women to have quality facility-based care.

A facility equipped to provide basic emergency obstetric and newborn care offers 7 signal functions: the administration of parenteral antibiotics, oxytocic drugs, and anticonvulsants; manual removal of the placenta; removal of retained products; assisted vaginal delivery; and neonatal resuscitation. A facility capable of comprehensive emergency obstetric care will be able to provide these 7 signal functions as well as perform cesarean deliveries and blood transfusions. All women should have the right to access these emergency obstetric care services to save their lives.

3. Access, coverage, quality: The inequities 

Although an increasing number of countries have succeeded in providing emergency obstetric and newborn care in recent years, the countries that began with the highest burdens of maternal and neonatal mortality and ill health made the least progress during the 1990s [10]. In some countries the situation has actually worsened, and worrying reversals in maternal and newborn mortality have taken place. Progress has slowed down and is increasingly uneven, leaving large disparities between regions and countries. Within one single country there are often striking inequities and differences between population groups, and national figures mask substantial internal variations—geographical, economic, and social [11], [12]. Rural populations have less access to skilled and emergency care than urban dwellers; among urban dwellers, mortality is higher in urban slum populations; rates can vary widely by ethnicity or by wealth status, and remote areas often bear a heavy burden of deaths. Moreover, ill health among pregnant women, and particularly the occurrence of major unpredictable obstetric problems and delayed care seeking, can lead to catastrophic expenditure that may push households into poverty and further exclusion in future [13]. Unless efforts are increased radically, there is little hope of eliminating the avoidable maternal and newborn mortality in many countries.

Fifteen percent of child births are expected to have complications that require emergency obstetric care [14], and all women with complications should have access to such care. Assessments in several countries find important gaps in coverage. One barrier to accessing emergency obstetric care is the lack of facilities near rural communities. Access is also hindered by lack of money, poor transport, and distance. Even when transport is available, it requires additional cost. Aside from these geographic and financial barriers, cultural barriers are also likely to prevent people from seeking emergency help. It is vital that the health facility has an effective infrastructure, medical equipment and supplies, and qualified staff to support women seeking care. Secondary analysis of Demographic and Health Surveys from 24 countries in Africa carried out by the Making Pregnancy Safer Department of the WHO shows the main barriers to accessing a health facility (Fig. 1). The sample used in the analysis consisted of data from 226350 women in the reference period from 2000 to 2006. Women were asked whether or not each of the factors would pose a problem in seeking care. The majority of women (57%) expressed that financial inability was the main reason for not accessing care at a health facility, and not a lack of knowledge. Distance or lack of transport was main reason for not accessing pregnancy and childbirth care services, particularly among rural poor women.

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Fig. 1. Reasons given for not attending a health facility.

Considering that cesarean deliveries may be necessary in 5% to 15% of births and are a proxy indicator for access to emergency obstetric and newborn care services, access to such services is unequal among countries (Fig. 2) and within countries. A study suggests that less than 1% of the poorest 20% of the population had access to the emergency care [15]. Fig. 3 shows cesarean delivery rates by urban, rural, and the poorest and richest wealth quintiles. The sample consists of data for 269127 deliveries ending in a live birth in the 5 years preceding surveys in 29 countries, in the reference period from 2002 to 2007. The sample included 19 countries in Africa, 5 in South and Southeast Asia, 1 in Latin America, 2 in Eurpoe and 2 in North Africa. These countries account for approximately 55% of births in the world when using birth estimates for 2005 [16]. Of those countries included in the analysis, 21 had a total cesarean delivery rate of below 5%, which is less than the recommended rate. Overall, except for a few countries, a higher cesarean delivery rate is skewed to births occurring in urban and wealthy women compared with rural and poor women. Cesarean delivery rates are considerably low among the poorest women. The extent of the gap between the rates among the wealthiest and the poorest women clearly highlights the existing disparity in accessing emergency obstetric care within these countries.

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Fig. 2. Percentage of births by cesarean delivery.

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Fig. 3. Percentage of births delivered by cesarean delivery by urban, rural, wealthiest, and poorest.

Scaling up the provision of emergency care is critical; however, much of the progress often occurs among the wealthiest in a population who have higher levels of education [17]. With an increase in urban slum areas in many parts of the world, the disparity in accessing emergency care within urban areas has also became prominent. Fig. 4 presents cesarean delivery rates among women living in urban areas by wealth quintile. The sample consists of data for 152770 deliveries resulting in live birth in 14 countries in Africa between 2003 and 2006. Estimates are based on the data referring to 5 years preceding the survey. Of those births delivered by cesarean, 4 out of 5 (83%) were performed among the urban richest and richer women, while only 1.6% of urban poorest women had access to the procedure. Universal access to emergency care services is paramount to save women's lives.

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Fig. 4. Cesarean delivery rate in urban areas by wealth quintile.

Given the distribution of qualified facilities across the health pyramid level and across ownership (public, private, and NGOs), the challenges in implementing and scaling-up universal coverage in resource-poor settings are substantial and discussion concerning priority-setting with existing resources is important. In terms of presence of qualified emergency obstetric care (EmOC) facilities, upgrading of existing non-qualified first referral hospitals to comprehensive (CEmOC) standard may be a priority. This is most likely a managerial task at facility, district, and regional levels. Additionally, and more relevant to long-term policy discussions and resource allocation debates, it is of vital importance to upgrade existing health facilities strategically located to become basic (BEmOC) facilities, particularly in rural areas [18].

4. Some innovative approaches 

Availability of facilities does not always ensure optimal utilization. In addition to improving quality of care at facilities, innovative approaches are needed to improve demand and utilization. In India, a program providing funds and financial incentives to mothers when they seek to deliver at a facility has led to a 10-fold increase in childbirth and emergency care at facilities (from 700000 beneficiaries in 2005/06), and has reportedly had a significant effect on increasing institutional deliveries including emergency care services among poor women [19]. In Gujarat, contracting with private obstetricians to provide services to poor women resulted in a major increase in obstetrician-assisted deliveries including emergency obstetric and newborn care in just 2 years. The introduction of result-based financing and social insurance in Rwanda has contributed to an increase in childbirth and emergency obstetric care in facilities from 39% to 52% over a 3-year period. The government also invested in building new facilities, providing equipment and supplies, as well as making available an adequate number of skilled healthcare providers at every facility. In a study conducted in 315 villages in Pakistan, community-based interventions increased the use of skilled birth attendance and facility care from 18% to 30%, which improved maternal health and survival [20]. Innovative approaches to reduce barriers significantly improve pregnant women's access to emergency obstetric care services and help improve their survival and health.

Finally, according to social-justice theories, inequity in health refers to inequities that are unjust [21]. The existing inequities in maternal deaths and access to maternal health services that are prevalent in most countries with high maternal mortality must be considered a social injustice and an infringement of pregnant women's rights to quality care to save their lives. Addressing inequities in maternal health should be viewed as a central policy goal, together with achieving the targets of MDG 5. There is a need to adopt strategies for rural and poor women to establish equity in terms of access to, and use of, maternal healthcare services including emergency obstetric care.

5. Conclusions 

The challenges of making pregnancy safer and addressing inequities are not new technologies or new knowledge about effective interventions; we know what needs to be done to save the lives of mothers and newborns. The challenges we face are how to deliver these services and scale-up the coverage and utilization of interventions, particularly to those who are vulnerable, hard to reach, marginalized, and excluded. Key constraints to progress are the serious shortages and mismatches between what is needed and what exists in terms of skills and geographical availability of human resources at local, national, and international levels. Other challenges are how to address the critical issues of health systems: the lack of facilities, deteriorating infrastructure, lack of drugs, dwindling supplies and equipment, lack of transport, ineffective referral to and availability of 24-hour quality services (particularly emergency obstetric care services), and weak management systems. We need to challenge our policy makers and program managers to refocus program content, to shift the focus from development of new technologies toward development of viable organizational strategies that manage and ensure a continuum of care, particularly access to emergency obstetric and newborn care for 24 hours 7 days a week, and to account for every birth and every death.