Trend 2015). Disparities between and within countries are

Trend over time of maternal mortality
worldwide from 2000 to 2015

2000 the United Nations Millennium Declaration set out targets known as the
Millennium Development Goals (MDGs) to improve the lives of the world’s poorest
people (World Health Organisation (WHO) 2015a).
Included in these goals was the aim to reduce the maternal mortality ratio (MMR,
number of maternal deaths per 100,000 live births) globally by 75% from 1990 to
2015 (United Nations (UN) 2015). An
ambitious goal, considering the 12% reduction which occurred in the previous
decade from 1990 (WHO et al. 2015). The major causes of maternal mortality (MM) include
haemorrhage, sepsis, pre-eclampsia and unsafe abortions however lives could be saved
if adequate contraception, abortion, ante; peri and post-natal care was available,
particularly in the developing world (UN 2015).
Considerable progress has been made, with global MMR reducing from 330 in 2000
to 216 in 2015, an admiral reduction but less than the 75% target, perhaps
reflecting an unrealistic goal from the outset (UN
2015). The estimated annual decline in MMR did however accelerate from
2000 to 2015 prompting optimism for the future (WHO
al. 2015).

the global reduction of MMR is impressive it must be noted just 51% of countries
provide, often incomplete, MM data (UN 2015).
Disparities between and within countries are also masked by this data, with 26
countries deemed to have made little or no progress reducing MMR and higher
MMRs noted among marginalised groups, when such data is available (WHO  et al. 2015). It must be considered
how many maternal deaths are masked or not accounted for in the data?

Challenges in reducing maternal

lack of accurate data on MM leads to difficulty determining the priorities to
target for improvement (UN 2015). It also
begs the question, if governments are oblivious to the true levels of MM, how
can improvements be prompted, or the effectiveness of any interventions be measured?

contraception, safe abortions and ante-, peri- and postnatal care can reduce
the risk of MM the lack of accessibility and use of such services is a
challenge to reducing MMR (Bullough et al. 2005; UN 2015). As
highlighted by the UN, 64% of women globally who wish to avoid pregnancy are using
contraception while just 28% of those in sub Saharan Africa are, only half of
women receive recommended antenatal care and 25% of babies are born without
skilled personnel (2015). In remote areas
the distance and cost required to travel to and avail of healthcare precludes
women attending (Kyei-Nimakoh et al. 2017).  In addition, numerous reports of mistreatment
et al. 2017), fear of disease transmission (WHO  et al. 2015), HIV diagnosis (Byford-Richardson
et al. 2013), lack of equipment and staff training deter many from
attending for reproductive care (Kambala et al. 2011). In areas where
accessibility to reproductive care is poor however caution must be exercised
before laying blame. The healthcare systems of many of these nations are
operating in fragile states under the burden of conflict and HIV epidemics
which present further challenges (WHO  et
al. 2015).

unique cultural and religious beliefs and practices throughout the world also
present a challenge to reducing MM (Evans 2013).
Women in many areas do not have the power to make decisions regarding their
health (Lori and Boyle 2011) and so are
less likely to seek advice regarding contraception, pregnancy and abortion (Osamor and Grady 2016). In Tibet pregnant
women believe contact with strangers such as healthcare staff may negatively
impact their health (Adams and White 2005),
while in Mozambique public knowledge of pregnancy is feared to increase
vulnerability to witchcraft (Chapman 2006).
Many women opt to seek care from traditional birthing assistants instead of or
in addition to medical care which they feel does not meet their spiritual and interpersonal
needs (Chapman 2006; Sarker et al. 2016). The unique cultural and religious beliefs of
different ethnicities make it challenging to develop global models aimed at
reducing MMR, but it is crucial they are respected and used to inform services
to ensure success (Evans 2013).

Innovations strategies that could be
implemented to reduce maternal mortality

WHO has identified many strategies to reduce MM including tackling inequalities
in accessing care, ensuring universal health coverage, increasing the strength
of healthcare systems, focussing on all causes of MM and ensuring
accountability to improve the standard and equity of care (WHO  2015b).

discussed, geography finance and gender inequalities may prevent access to
services aimed at optimising maternal health (Kyei-Nimakoh et al. 2017). Initiatives such
as maternity waiting homes (MWH), community outreach programmes and subsidies
have led to improvements in MM (United Nations
Children’s Fund (UNICEF) 2013). While it is crucial barriers don’t
preclude access to adequate care it is also imperative that once accessed the
healthcare provided is culturally acceptable (Evans
2013). In Afghanistan for example while some MWHs are available many
women were not admitted as their families prohibited them from staying (UNICEF 2013). Ensuring adequate training of
staff to provide quality, respectful care is also imperative to increase the
acceptability of medical over traditional care (UNICEF
2013). Investments in staff training in Cambodia for example led to an
increased proportion of births being attended by skilled personnel (UNICEF 2013). Further research in the form of
randomised control trials are needed however to demonstrate which initiatives
work best to help guide the optimal use of resources.

the WHO advocate tackling all causes of MM little focus appears to be directed
towards strategies to increase contraceptive use or safe abortion practices. A
review of both ‘Innovative Approaches to Maternal and New-born Health’ (UNICEF 2013) and ‘Strategies Toward Ending
Preventable Maternal Mortality’ (WHO 2015b)
yielded no specific guidance on tackling these issues. Further attention is
needed in these areas considering the significant effects they can have on
reducing MM (Ahmed et al. 2012).

data collection including maternal death audits, verbal autopsies and near miss
reports have been instrumental in improving the quality, equity and
accountability of care and so MMR in areas such as India (Padmanaban et
al. 2009; UNICEF 2013).  Improved
data collection alone is not enough however, to be effective results must be
interpreted, cause of death identified, and action taken to prevent further maternal
deaths (UNICEF 2013). With 49% of countries
having little information on MM the potential benefits of such strategies could
be enormous.

admiral reductions in MM have been achieved much still needs to be done. While
this is an area of challenge it is also an area of opportunity to instigate