Maternal Health PUBHLTH 350 Matthew L. Boulton, MD, MPH October 20, 2014

Outline Definition Maternal mortality Inequalities in maternal health Neonatal mortality Causes Solutions Global maternal health initiatives and rights

What is maternal health?

Maternal health Health of women during pregnancy, childbirth, and postpartum period Many women globally suffer from ill- health or mortality from causes and in patterns that differ from males Significant female morbidity and mortality is related to pregnancy and childbirth

Maternal Mortality Approximately 289,000 women died worldwide during pregnancy and childbirth in 2013 –Decline of 45% since 1990 –Some countries in Asia and Northern Africa have more than halved maternal mortality –Majority lack access to skilled routine and emergency care –Non-institutional births and/or lack of a skilled birth attendant are both associated with poorer maternal and neonatal outcomes

Map of Maternal Mortality

Disparities in Pregnancy-related Mortality in the US Deaths per 100,000 live births: –12.5 for white women –42.8 for black women –17.3 for women of other races

Inequalities in Maternal Health Though rates are decreasing, significant regional disparities remain South Asia and sub-Saharan Africa account for ~90% of maternal deaths

Inequalities in Maternal Health Risk of dying during pregnancy and childbirth is markedly different in regions –Developed countries: 1 in 3700 women –Sub-Saharan Africa: 1 in 38 women

Neonatal Mortality Causes of newborn death, maternal death, and infant survival are closely linked ~3 million babies die in their first month of life 1 million newborns don’t survive the first day of life 80% of newborn deaths are caused by prematurity, complications during childbirth, and infections Mostly occurs in low income countries

Jacobsen chapters 5. Child health; and 6. Health of younger adults.

Neonatal Mortality Like majority of maternal deaths, most newborn deaths could be prevented through already available, proven and low- cost maternal and newborn health-care interventions

Causes of Neonatal Mortality

Jacobsen chapters 5. Child health; and 6. Health of younger adults.

Causes of Maternal Mortality Major cause of morbidity and mortality include hemorrhage, infection, high blood pressure, unsafe abortion, and obstructed labor

The Causes and The Solutions

Solutions for Maternal Mortality Globally, >10% women do not have access to or are not using effective methods of contraception –Addressing family planning needs could reduce maternal mortality by estimated one third Also important that women seek care during childbirth in health facilities to ensure quality of care is optimal –Use of skilled birth attendants Vaccines during pregnancy

Vaccines During Pregnancy Pregnancy is a vulnerable period for VPD-associated complications for both mother and baby Vaccines prevent maternal and congenital disease Vaccines provide direct fetal/infant protection via passive immunity Administered during pregnancy and postpartum

Vaccines During Pregnancy No risk with inactivated virus or bacterial vaccines or toxoids Live vaccines pose a theoretical risk to the fetus Benefits usually outweigh potential risks when likelihood of disease exposure is high, when infection would pose a risk to mother or fetus, and when vaccine is unlikely to cause harm

Solutions for Neonatal Mortality Mother –Proper nutrition and breastfeeding –Imparting passive immunity Vaccines –Active immunity

Undernutrition & Breastfeeding Undernutrition: taking in too few calories or inadequate amounts of specific nutrients (proteins, fats/oils, vitamins, minerals) Recommendations –Exclusive breastfeeding for 6 months –Introduction of complementary foods at 6 months with continued breastfeeding for up to 2 years International Code of Marketing of Breast-milk Substitutes Jacobsen chapters 5. Child health; and 6. Health of younger adults.

Maternal Health Initiatives MDG 5: Improve maternal health –Target 5.A. Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio –Target 5.B. Achieve, by 2015, universal access to reproductive health UN Secretary-General's Global Strategy for Women's and Children's Health: –To prevent 33 million unwanted pregnancies between 2011 and 2015 –To save the lives of women who are at risk of dying of complications during pregnancy and childbirth, including unsafe abortion

WHO Key Working Areas Strengthening health systems and promoting interventions focusing on policies and strategies that work, are pro-poor and cost-effective Monitoring and evaluating the burden of maternal and newborn ill- health and its impact on societies and their socio-economic development Building effective partnerships in order to make best use of scarce resources and minimize duplication in efforts to improve maternal and newborn health Advocating for investment in maternal and newborn health by highlighting the social and economic benefits and by emphasizing maternal mortality as human rights and equity issue Coordinating research, with wide-scale application, that focuses on improving maternal health in pregnancy and during and after childbirth

Progress on MDGs Progress towards the MDG objective has been slow, despite a widespread global commitment 99% of maternal deaths occurring in developing countries can be prevented through well known interventions With widespread commitment and proven solutions, why such slow progress?

Maternal Health Rights UN Human Rights Council highlighted maternal mortality as not just a development issue, but a human rights issue –Strengthening human rights accountability is an essential but neglected strategy for improving women’s and children’s health and reducing maternal mortality –Linking accountability with human rights provides the framework on right to health, equity in health and gender equality

Maternal Health Rights Case August 2011, the Committee on the Elimination of Discrimination against Women became the first UN human rights body to issue a decision on maternal mortality Alyne da Silva Pimentel v. Brazil established that States have a human rights obligation to guarantee women of all racial and economic backgrounds timely and non- discriminatory access to appropriate maternal health services

Whose rights should come first, a mother’s or child’s?