Quality maternal care for every woman

Faculty Author Q&A

Call to Action

BY LAUREN CRAWFORD
Summer 2017
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In 2015, more than 300,000 women died worldwide due to causes related to maternal health. The majority of these women succumbed to preventable complications, such as hemorrhage or infection. Women in developing nations were 33 times more likely to die due to maternal complications than those in developed countries. Prompted by these staggering statistics and disparities, Cheryl Moyer, Ph.D., M.P.H., assistant professor of learning health sciences and of obstetrics and gynecology, co-wrote “Quality Maternal Care for Every Woman, Everywhere: A Call to Action,” published in The Lancet. The article enumerates methods of reaching the Sustainable Development Goal ratio of “less than 70 maternal deaths per 100,000 livebirths by 2030.” Medicine at Michigan spoke to Moyer about this goal and how to achieve it.

The article is a call to action.” Why was it necessary to frame it this way? What action needs to be taken?

It’s difficult to answer this question without taking a step back to discuss the context in which this series was conceived, written, and launched.

Back in 2000, the United Nations led a movement to help focus global efforts on several key issues, including eradicating poverty, achieving universal primary education, promoting gender equality, reducing child mortality, improving maternal health, combating HIV/AIDS, malaria and other diseases, ensuring environmental sustainability, and developing global partnerships for economic development. These goals, known as the Millennium Development Goals, or MDGs, included very specific language around maternal health, including Goal 5: to reduce the maternal mortality ratio within each country by 75 percent by 2015 (from whatever their ratio was in 1990). The MDGs also included Goal 5A: to achieve universal access to reproductive services by 2015, including a contraceptive service provision and antenatal care. During the MDG era, in large part because of the focused attention on a few key indicators, we saw fairly significant improvements. For example, we saw a global reduction of the maternal mortality ratio of 43 percent. While that wasn’t the 75 percent we hoped to see, some countries met or even exceeded their MDG target. However, many others fell short. In addition, while some countries made improvements in their overall rates, certain subgroups and subpopulations were left behind. (Note that this is not unique to developing countries: We see similar disparities in the United States, too.)

Then, in 2015, with the “end” of the MDGs, countries around the world adopted a new set of 17 broad goals to end poverty, protect the planet, and foster ethical, equitable and sustainable development. These goals are known as the Sustainable Development Goals, or SDGs, and they were designed to build upon the MDGs. But in many ways, they are much more broad, and some of the specific targets for maternal health are much less prominent. For example, in the MDG era, there were 8 specific goals, and Goal 5 was focused on maternal health. In the SDG era, there are 17 specific goals, and maternal health is nested within Goal 3, which is to promote health and wellbeing. Within Goal 3 of the 17 SDGs, there are 13 targets, one of which is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births and another to ensure universal access to reproductive health services by 2030. The point is that while maternal health was a clear focal point of the MDGs, the SDGs take a much broader view of what is needed globally. While that is not necessarily negative, it means that attention is diffused and some of the focused efforts around maternal health may not be as high of a priority as they once were. In that context, the Lancet Maternal Health Series was born.

The Series builds on a previous Lancet Maternal Health Series that was published in 2006 and provides not only an update on all that has happened in the 10 years since then, but it also seeks to emphasize that while progress has been made, our work is nowhere near done. That was part of the impetus behind calling our paper a Call to Action. We wanted researchers, policy makers and government leaders to understand that this is not the time to get complacent or to think that maternal health issues have been “solved.” Especially in the face of competing demands, like dealing with armed conflict and displaced populations and the challenges of immigration, it’s sometimes hard to remember that maternal health is an important part of all of that. And unless it is prioritized alongside such issues, any progress that has been made thus far is likely to be reversed.

Preventing unwanted pregnancies would be a huge component of the success of the SDGs. But contraceptive and abortion services are often highly stigmatized and under-funded. How would the SDG account for this?

This is a great question, one that is especially pertinent in today’s political climate. Unfortunately, there are also no simple answers. The SDGs are global goals, ones that were developed and ratified by 193 member countries in 2015, but they are not legally binding. So while one of the targets is universal access to contraceptive services, for example, there is no enforcement mechanism in the event a country does not want to prioritize contraceptive access. The hard part for me is to see so clearly that lack of access to contraceptive and abortion services leads to the deaths of tens of thousands of young women in low-resource settings — which feels to me like a statement about their societal worth. So while I can understand some of the reasons why people may object to contraception and abortion services, the truth is that in many places, women are dying from lack of access. Complications from unsafe abortion is the fourth or fifth leading cause of all maternal deaths, depending on which source you use.

What cultural and societal pressures might be at play here?

[T]he reason abortions are necessary is often because of lack of access to safe, low-cost, culturally appropriate contraception. That’s a problem. It is also, in my opinion, a bit unfair that conversations about contraception and abortion rarely include the broader social and cultural issues such as gender inequality, education, sexual violence against women, cultural expectations surrounding sexuality and fertility, and also the role of health care providers in delivering judgment-free care. This is not simply about the women. It is about the society they live in, the men who live alongside them and circumstances that make women vulnerable to unwanted, unprotected sexual encounters. These issues are extremely complex and interrelated, and I am not sure the SDGs alone can address them. That said, it is not just governments that play a role in the success or failure of the SDGs and the targets around reproductive health services. It is up to all of us. It means supporting organizations that advocate for and provide contraceptive services both here in the United States and abroad. It means supporting legislation that supports under-resourced areas of our state and our country and gives access to women in marginalized communities or in states with particularly restrictive policies. So while it may feel easier to think that these issues are not relevant in the United States and really only affect poor women in low-resource countries, nothing could be further from the truth.

There is an assumption that developing nations need the most intervention, but, between 1990 and 2015, maternal mortality actually increased in the U.S. How do these assumptions impact progress?

I think one of the most important aspects of this Lancet series is the reminder that we are all in this together. High-income countries like the United States certainly don’t have all the answers, and we still have groups of women who experience disproportionate risks of morbidity and mortality. The truth is, if a woman is poor, not well educated, not surrounded by a supportive social network and does not have access to high quality healthcare, she is likely to have a worse outcome than a woman in better circumstances, regardless of whether she lives in the Upper Peninsula or Uganda. So while the raw numbers of deaths are higher in low-resource countries, there are still groups of women in the United States who suffer disproportionately. We see this among low-income women, women who are uninsured and also among women who live in different states. For example, women without health insurance are three to four times more likely to die of pregnancy-related complications than women with insurance in the U.S. And a recent paper that compared state-by-state mortality rates showed that women in Texas have double the risk of maternal mortality than women in any other state. (See MacDorman MF et al., Obstetrics & Gynecology, September 2016.) While some of this can be attributed to how different states implement health care, that’s not the whole story.

One of the papers in the Lancet Series is titled, “Beyond Too Little, Too Late and Too Much, Too Soon,” referring to two extremes of maternity care. “Too little, too late” describes care with inadequate resources, below evidence-based standards, or care that is withheld or not available until it is too late to help. “Too much, too soon” describes the routine over-medicalization of normal pregnancy and birth and includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life-saving when used appropriately, but harmful when overused. Both of these are very real issues that need to be addressed to optimize maternal health, and both are relevant in the United States as well as in low-resource settings.

Building on this, the article stresses that “dual streams” of poor-quality care and inaccessibility exist everywhere, regardless of the nation’s income. What are some steps health systems can take to bridge those gaps?

This is a politically charged question and the answer will undoubtedly vary based upon one’s beliefs about the role of government in providing health care, whether health care is a right or privilege, and whether health care is akin to a commodity that will bow to market forces or whether health care services cannot be treated like any other commodity. That said, there was a general sense among the authors that “dual streams” of care, in which wealthy people get one type of care while the poor get another, can be mitigated (although perhaps not eliminated) by a single-payer system with universal coverage. And yet setting up a single-payer system is not easy, nor is it politically palatable in many places.

Inaccessibility is another challenge entirely, as “access” includes far more than geographical accessibility. Researchers have created a taxonomy for access that they call the Five As of Access: Affordability, Availability, Accessibility, Accommodation and Acceptability. Affordability is just like it sounds: Can the patient afford the services offered or the co-pay on those services? Availability includes the presence of trained providers with up-to-date equipment who can see patients promptly. One can argue that needing to wait six months for an appointment with an ill-trained provider is care that is not readily available. Accessibility is the geographic proximity of care, and whether patients can easily get to the facility. Accommodation refers to whether providers are available when patients need them, such as during evenings or weekends. Acceptability, the last type of access, refers to whether the care being offered is socially acceptable to the patient. This includes cultural appropriateness (e.g. appreciating patients’ cultural preferences during care) as well as whether the care is provided in a welcoming, supportive manner. For example, a young pregnant woman may not be getting acceptable care if her provider berates her for becoming pregnant, encourages her to get an abortion or encourages her to put her baby up for adoption.
Addressing these elements of access is not easy. It requires thoughtful training of providers that moves beyond technical skill and incorporates some of the sociocultural elements of care. It requires incentivizing providers to practice in under-served areas. It requires incentivizing extended office hours and weekend coverage. And it requires addressing not only the cost of health care, but the details of insurance coverage to make sure patients can actually afford their co-payments, their prescription drugs and the other associated costs of care.

Much of what the article endorses is “women-centered,” respectful care. What does this look like in both the U.S. and across the globe? What should it look like?

There is increasing recognition that respectful care is a crucial element in maternal health. That’s not just because it’s the right thing to do — it’s because it influences whether women come back for future care themselves, whether they encourage their friends and family members to seek care and whether they follow the directions given by providers when they leave the facility. In many low-resource settings, it is not uncommon for women in labor to be yelled at, beaten, slapped or shamed by health care providers. While this may sound appalling, it is important to remember that it often occurs in a context where a single provider is responsible for multiple deliveries at the same time, there is no anesthesia and laboring women are in excruciating pain, and patients have had little education on what to expect or what can be done to assist in their own deliveries. For example, when a woman won’t push during contractions, and the provider has no medication, lacks the ability to provide an emergency cesarean section, and knows that if the baby doesn’t come out soon it will die, he or she may yell at the woman, slap her or do whatever they can to make her push. While this is a classic example of disrespectful care, it is worth noting that it is a systemic problem rather than simply a problem with an individual provider. That’s not to say there are not providers who abuse patients regardless of the circumstances, but it’s not always as simple as blaming the providers.

In the United States, providers may not generally yell at, beat or slap women, but there are other ways in which care is delivered that are less than respectful. For example, not all providers ask women’s permission before conducting pelvic exams during labor. Not all providers respect women’s privacy by keeping curtains closed or keeping women draped. Not all providers actively listen to patients’ questions and concerns, and not all providers actively solicit or respond to patient input. Not all providers discuss options with women and their families as decisions are being made, and while time sensitivity may be the justification for rapid decision-making, it speaks to a lack of advance discussions and expectation management when women later feel as though their delivery was hijacked and procedures were done that they don’t feel like they understood or necessarily wanted.

The White Ribbon Alliance has done some excellent work articulating what respectful care looks like and advocating for its inclusion in country-level health plans. I think the point of including respectful care so prominently in this Lancet Series is to remind us all that maternal health is about more than just the clinical outcome — it is about the whole woman, and her experience of care matters.

If the SGDs succeed in upholding a baseline of care worldwide, what will the next step be?

It is not clear what will come after the SDGs, regardless of whether they are achieved. The SDGs run through 2030 and it is hard to say where things will stand by then. That is more than three U.S. presidential election cycles away, as well as two World Health Organization director general and two United Nations secretary general terms away. I can only hope that we have strong global leadership that values collaboration, understands the inextricable links that connect us all and prioritizes maternal health alongside other important issues such as education, economic development, environmental protections and peace.

Is there anything else you would like to add or comment on?

The Lancet series spotlights many aspects of maternal health, but one of the things that I was most struck by in working on the series was the number of issues that are directly related to maternal health that we simply did not have space in six manuscripts to address in a meaningful way. For example, what about the unique issues facing adolescent girls throughout the world? What about abortion, contraception and family planning? What about women’s mental health, from adolescence through aging? What about maternal nutrition? What about the intersection of maternal, newborn and child health as a continuum? What about the increasing role of non-communicable diseases in women’s health? What about aging and how that differs for women around the world? What about the changing role of technology in impacting maternal health, or women’s health more broadly? The bottom line is that maternal health cannot be seen in a vacuum. So while I think the series is an excellent contribution to what we knew about maternal health in 2016, in many cases it raised more questions for me than it answered. Perhaps that is the hallmark of a good series — one that provokes and sparks further research.

Illustration by Edmon de Haro