No Cause for Complacency on Maternal Health


New estimates of maternal mortality just published in the Lancet suggest encouraging—and long overdue—progress on what for too many years has seemed an intractable problem. According to an analysis by researchers at the Institute for Health Metrics and Evaluation (IHME), maternal deaths fell from more than 500,000 in 1980 to about 343,000 in 2008—a decline that far surpasses previous United Nations estimates.

The global health community is rightfully celebrating this news, which many see as the strongest evidence yet that investing in reproductive health, girls’ education and economic development yields tangible positive results.

Advocates for women’s health also correctly caution against complacency, though, since deaths related to pregnancy and childbirth are notoriously among the most poorly captured health data. Moreover, even the new, much lower numbers are far too high. Almost all maternal deaths can be prevented with known technologies and public-health interventions, and the death of even one woman is too many.

And while more robust scientific evidence and debate are certainly to be applauded, advocates cannot be faulted for worrying that signs of progress could lead to diminished investment in women’s health. After all, the international community does not have a very good record of summoning the political will to address women’s — especially poor women’s — health.

This too-common failure to muster political will on behalf of poor women is especially true when it comes to unsafe abortion, a critical contributor to maternal deaths and injuries that authors of the new Lancet article do not even mention.

Without adequate access to contraceptive information and methods, about 80 million women and girls around the world face unintended pregnancies every year. Without access to safe abortion —severely restricted by law in most developing countries — many resort to unsafe methods and unqualified practitioners to end those pregnancies. According to the World Health Organization, about 66,500 women die and at least 5 million are hospitalized every year as a result. Unsafe abortion is estimated to account for about 13 percent of global maternal mortality.

Margaret Hogan and her IHME colleagues note that many pregnancy-related deaths are not classified as such in vital registration records, a main data source for their study; they were careful to calculate an adjustment to account for that fact. They fail to note, however, that many deaths related to abortion are likely not to be reported or recorded as such, reflecting the strong, pervasive stigma and secrecy that surround unwanted pregnancy and abortion.

Yet, with known technologies, unsafe abortion is one of easiest causes of maternal mortality and morbidity to address, through improved access to contraception, treatment for abortion complications and safe abortion. Indeed, we now have strong evidence from numerous countries that legalizing abortion — which more and more countries are doing — and making safe services available leads to dramatic improvements in women’s health, saving many lives. For example, South Africa saw abortion-related maternal mortality decline by more than 90 percent after expanding access to legal abortion in 1997. Early results from Ethiopia, which expanded legal abortion in 2005, show that safe, legal procedures are beginning to displace unsafe abortions, reducing women’s need for emergency treatment of complications. 

United Nations agencies are expected to issue new maternal mortality and unsafe abortion estimates soon; we hope that they too will indicate positive trends. But improved systems for data collection are urgently needed, to guide policies and programs to address preventable causes of maternal deaths — especially abortion.

One important contribution Hogan and her colleagues have made is to call attention to the high number of maternal deaths among pregnant women and mothers who are HIV-positive. Were it not for the HIV epidemic, they say, about 61,000 fewer women would have died in 2008. They and others are right to call for better integration of maternal health care and HIV prevention and treatment, which could indeed save many lives.

But even more women and girls could be saved — and more easily — if the global health community at last applied what it already knows about preventing deaths and injuries from unsafe abortion. As we strive together to understand and digest the implications of these encouraging new maternal mortality estimates, and to identify and replicate successful interventions, let us also have the political courage to commit resources to the most controversial public-health issues. Improving access to contraception, postabortion care and safe, legal abortion works, and we must accelerate and greatly expand efforts to address these fundamental women’s rights.

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