Beyond survival, beyond childbirth: a paradigm shift in maternal health

“In our society, the joy of having a newborn is cherished by everyone, but the pain, physical exertion, psychological trauma, and other sequelae of pregnancy and labour are borne by the mother alone.” – Sayeba Akhter

In 2020, an estimated 287,000 women died from causes related to pregnancy, childbirth, and the postnatal period. 95% of maternal deaths occur in low- and middle-income countries (LMICs).

While there has been a decline in maternal mortality since the first global estimates in the 1980s and early 1990s, the pace of progress has fallen short of expectations. At this halfway point to achieving the Sustainable Development Goals, “reaching a global mortality ratio (MMR) of 70 maternal deaths per 100,000 live births remains elusive”, say authors of a new Lancet Global Health–eClinicalMedicine Series.

The leading biomedical causes of maternal death have been a core focus; “[this] has possibly been the cause of many counties remaining at the same maternal mortality transition stage for decades”, authors write. They add that “most maternal deaths remain preventable and are largely clustered among groups of socioeconomically disadvantaged women.”

Moving beyond the biomedical

The Series highlights the significance of factors ranging from climate events and the biology of humans (so-called “superdeterminants”) to racial and gender inequities (social determinants) in shaping the environments in which people who become pregnant are born, grow, live, and give birth. Various “vulnerabilities” can also impact the maternal health trajectory. For example, nutritional deficiencies, low education levels, and migrant and refugee status are known to affect outcomes adversely.

“Maternal health is a social issue: maternal ill-health and disability are not just medical problems, but outcomes of a complex interplay of eco-social forces, lifestyles, and individual-level factors.”

Then, there is the birthing experience itself. In a Comment, obstetrician Sayeba Akhter writes: “Although my delivery was conducted by one of the senior obstetricians, I did not feel reassured or safe because I didn’t find the attitude of the doctors and labour room staff to be patient-friendly and sympathetic at that moment [...] the feeling of not being seen or heard was a negative delivery experience.” She goes on to describe an episiotomy that “made my life hell during the next couple of years.”

What clearly emerges from the evidence set out by the Series is that maternal health does not begin or end with childbirth, nor with the biomedical. “The current dictum from health authorities is that the six weeks after birth constitute the postnatal period. This timeframe is too short, and it does a huge disservice to women who still experience the effects of pregnancy and childbirth months, years, or even decades later”, states an Editorial in The Lancet Global Health. 

Long-term maternal health conditions

New research reveals a high burden of postnatal conditions that can persist long after giving birth: pain during sexual intercourse (dyspareunia), affecting more than a third (35%) of postpartum women, low back pain (32%), anal incontinence (19%), urinary incontinence (8-31%), anxiety (9-24%), depression (11-17%), and more.

“Even a healthy pregnancy can have a profound impacts on a woman’s body and mind, long after labour has finished... The health of that pregnancy is often heavily influenced by factors occurring long before a person even enters that first antenatal appointment”, said Dr Kate McIntosh, Senior Editor of The Lancet Global Health, at the Series launch. She added that “pregnancy and childbirth are not a single health event that occurs in isolation; [they] are experienced by a woman in the broad, rich context of her life.”

“The absence of [postnatal complications that can emerge months or years after childbirth] from the global health agenda and national action plans has led to the misconception that they are uncommon or unimportant.”

The protective role of health systems

Here is where quality health care, education, and universal health coverage play a vital role; “The health system can be considered a decisive protective factor, able to neutralise or minimise the effects of detrimental risk factors [in maternal health]”, authors suggest. Examples of reparative strategies include iron and calcium supplementation, community-based educational programmes, and contraception-promoting interventions.

However, health systems and professionals do not operate in a vacuum and can contribute to environments that minimise the voice and autonomy of a pregnant woman, inadvertently or otherwise. A perspective change is needed. The focus of maternal health must move away from narrow, syndrome-based management to a life-course approach with greater attention to the human rights, dignity, empowerment, and individual needs of women. This new Lancet Global Health–eClinical Medicine Series provides the scientific and moral basis for doing so.

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Visit the Lancet Maternal health in the perinatal period and beyond Series hub to find out more.