During a recent trip to Tanzania, I had the opportunity to reflect on broader women’s health issues in a way that I hadn’t done before. To cut to the chase, there is no doubt that, in developing countries, high maternal mortality rates, reflecting the large numbers of deaths of women during or just after pregnancy, is a terrible problem that deserves more attention and resources. Many – if not most – of the nearly 300,000 maternal deaths that occur every year could be avoided if women in those countries had the same kind of access to emergency care and access to contraception that women in the United States and other industrialized countries take for granted. Based in part on what I saw in Tanzania, I recently wrote the report – Improving Maternal Mortality and Other Aspects of Women’s Health: The United States’ Global Role – that addresses key challenges to improving maternal mortality and women’s health worldwide and talks about what the related priorities of U.S. foreign policy should be.
The tragedy of maternal mortality deserves all the attention it currently gets – and much more. But it would be a mistake to think of women’s poor pregnancy outcomes as an isolated set of purely medical challenges that can be solved by a narrow focus on emergency care.
First, some pregnancy-related deaths are not included in the current definition of maternal mortality. For example, recent research indicates that women who survive difficult labors and deliveries have a mortality risk six times higher than the risk faced by women whose pregnancy was normal. This excess mortality risk lasts as long as four years after the high risk delivery. However, the currently accepted definition of maternal mortality does not include maternal deaths that occur more than 42 days after delivery. (An extended definition of the maternal period to include the first 12 months after delivery has been proposed but has not yet come into widespread use.) Another source of undercounting of pregnancy deaths is the specific exclusion of homicide and suicide as causes of maternal deaths. Although there is strong evidence that pregnant women in many countries are at increased risk of homicide – and suggestive evidence for risk of suicide – neither of these causes are included specifically in the current definition of maternal mortality, which excludes deaths “…from accidental or incidental injuries.”
It is also clear that death of pregnant women is not the only severe maternal outcome of pregnancy. For every woman who dies because of events related to a pregnancy, there are anywhere from 15-30 other women who survive pregnancy, but suffer one or more long-term or permanent pregnancy-related physical or social disabilities, including – but not limited to – infertility, prolapsed uterus, severe nutritional deficiencies, severe post-partum depression, or other long-term challenges. For example, one of the worst consequences of a prolonged or “obstructed” labor at the end of an otherwise normal pregnancy is development of an obstetric fistula, caused by the intense pressures on maternal organs generated by the muscles of the uterus as prolonged efforts to expel the baby fail. As a consequence of the resulting leakage of urine or feces, women with obstetric fistulas often suffer from social exclusion, chronic urinary or fecal incontinence, and other health problems. The World Health Organization estimates that as many as 2 million women, mostly in Sub-Saharan Africa and South Asia, are now living with untreated obstetric fistulas, with 50,000-100,000 more women added to the toll each year. It is particularly tragic that prolonged or obstructed labor occurs most often in younger adolescents, because their pelvic structures are not yet mature.
Because of the clear association between unplanned pregnancies and maternal mortality, decreasing unplanned pregnancies through various mean (e.g., addressing the unmet need for family planning, reducing sexual violence, reducing numbers of child marriages) would help reduce numbers of both maternal deaths and the non-fatal but severe adverse maternal outcomes of pregnancy noted earlier. In fact, a recent detailed study of information from 167 countries found that just addressing the unmet need for family planning in those countries would reduce maternal mortality by 29 percent. Presumably, the non-fatal but severe outcomes would be reduced to a similar degree.
Also, some women in their child-bearing years are unable to have children; others choose not to become pregnant. In addition, aging populations in most countries include growing numbers of post-menopausal women. For these groups and for other women, a number of important health challenges remain that are not directly related to pregnancy. For example, the prevention, early detection, and adequate treatment of cervical cancer, breast cancer, and sexually transmitted infections are each ongoing challenges to women’s health in all countries.
Rather than continuing what appears to me as a piecemeal approach to global aspects of reproductive health, with separate programs to address, e.g., gender-based violence, women and HIV/AIDS, maternal mortality, family planning, cervical cancer, girls’ education, etc., I argue in my report that the United States should develop and implement a comprehensive global plan for women’s health that includes males as well as females, using coordinated prevention and care programming for each stage of the reproductive health life cycle.
* Phillip Nieburg, Senior Associate, Global Health Policy Center, CSIS*