Preventable: What the World Gets Wrong About Maternal Mortality

Author Note: The final paper for Gender and Politics at GPS, submitted in March 2024. The title says everything: over 800 women died per day in 2017 from pregnancy and childbirth complications, most of which were preventable. The paper traces why prevention keeps failing — through cultural practices, healthcare discrimination, education gaps, and the systematic exclusion of men from maternal care conversations — and proposes three interventions, the most underrated of which is subsidizing and properly training traditional birth attendants. The Dr. Natalia Kanem quote in the racial discrimination section stayed with me long after I submitted this.

Preventable: Global Disparities and Maternal Mortality

Introduction

Reproductive healthcare is an integral component of holistic health, encompassing sexual and reproductive well-being. As per the World Health Organization (WHO), it is a state of total well being -- physical, mental, and social -- as it relates to the reproductive system. Despite its criticality, it severely lacks policy and social support to address the variegated and intersected issues affecting the majority of the world; barriers include stigma and healthcare discrimination. These challenges disproportionately affect developing or marginalized communities. Maternal mortality, in particular, is a reminder of the urgency of this issue; of all health indicators, these “reveal the greatest gap between developed and developing countries,” and unveils intranational disparities between rural, low-income, or “non-white” women. Maternal mortality is a stark reminder of preventable deaths and the need for equitable reproductive healthcare on a global scale. 

Maternal Mortality

Maternal mortality, or the “ death of a woman while pregnant or within 42 daystermination of pregnancy... from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes,” is a key indicator of development and human rights^,. The WHO found that in 2017, over 800 women died per day due to pregnancy and childbirth complications. Most could have been prevented, if not for a lack of resources. In fact, 

“The primary causes of death are haemorrhage, hypertension, infections, and indirect causes… the risk of a woman in a low income country dying from a maternal-related cause during her lifetime is about 130 times higher compared to a woman living in a high income country”.

This is a direct indicator of a country's overall health, as it can be prevented through intervention and healthcare access. Even so, countries classified as developed or with lower mortality rates still display “marked differences” between demographics of women, “implying de facto discrimination” and non-equitable access. 

Basic obstetric care throughout pregnancy, such as physical exams and ultrasounds, is essential to ensuring the health of the mother and fetus. The Office of the United Nations High Commissioner for Human Rights (OHCHR) Convention on the Elimination of All Forms of Discrimination Against Women states “parties shall ensure to women appropriate services in connection with pregnancy, confinement and the postnatal period, granting free services where necessary”. Other OHCHR committees posit that it is the States’ obligation to provide this economic, social, and cultural right and that a lack thereof constitutes severe neglect. If solved every region reached the standards posed by the convention and the EU, there would be approximately a 95% reduction in mortality globally. 

Yet there are several factors that prevent women from receiving -- or even seeking -- care, such as health system discrimination, social determinants like education and gender norms, and external factors like violence. 

Socio-Cultural Norms

There are many entryways into this factor; culture and stigma play a crucial role, which is then exacerbated by a lack of education, and eventually leads to healthcare discrimination. 

Cultural Practices

Extant literature acknowledges that cultural customs and values “profoundly influence women’s behaviors during the perinatal period and in some cases increase the likelihood of maternal death,” as they accommodate both “directly harmful acts” and inaction, thereby exacerbating risks. It is an especially neglected problem in societies where cultural norms and stigmas trump legal action as well as in developing nations that turn their attention to other “more pressing” issues such as economic development -- without realizing that this issue is critical to progress. 

In one study from South Punjab, Pakistan, a country behind in gender equality (despite government efforts), superstitions and power dynamics heavily influence maternal health choices. For example, some women are cloistered indoors for months because of the fear that going outside pregnant will cause harm to the child -- but this actually has negative effects on the mother, depriving her of vitamins and also weakening mental faculties. Superstition also delays or interferes with prenatal care. Another example came from some women in Mozambique, where economic insecurity exacerbates vulnerability, competitions for male support, and social pressures to reproduce. Many stated that they believed that “they and their unborn infants will be targets of witchcraft or sorcery by jealous neighbors and kin,” and then “respond by hiding pregnancy and delaying prenatal care”. This then limits the ability to detect pregnancy issues that could later turn fatal. Another issue, a segue into stigma, is the strict adherence to traditional birthing practices or the use of traditional attendants like midwives, and the belief in many developing or traditional countries that “maternal death [is] a sad but normal event,” decreasing the likelihood to request assistance when needed -- increasing preventable death rates. 

Stigma

Factors varying from religion to immigration affect the way stigma and discrimination manifest in society -- often compounding and exacerbating factors relating to how they are “perceived, anticipated, or experienced”. In one case study, over 50% of Kenyan secondary school students were found to have “stigmatizing attitudes towards abortion and contraceptive use,” a direct factor of norms and cultural traditions. This translates into unsafe sexual practices, repeated pregnancies, and often, mortality. 

Social psychologist and stigma researcher Valerie Enshaw, PhD, states that stigmas are created to enforce social norms, exacerbating public health concerns. The basic message is that “you’ve done something wrong,” relating to any aspect of reproductive health -- which then translates to a lack of care and potentially rejection from community members. Over time, shame about sex became ingrained in religious institutions, schools, laws, and popular media. This stigma prevents individuals from seeking help and perpetrates ideas that eventually become institutionalized -- even in healthcare.

Discrimination 

Discrimination often stems from stigma; structurally, it occurs when “societal conditions constrain wellbeing and access to opportunities and resources, such as health services and good quality care”. Racial discrimination is one of the biggest issues, often the largest issue in nations with better healthcare, as disparities were diminished to prioritize literal care over community care. A U.N. survey across countries in the Americas found that black or indigenous women were more likely than white counterparts to experience complications or treatment-related abuse. The researchers found that medical curriculums often include “erroneous claims that Black women’s nerve endings are “less sensitive” and require less anesthesia” or that “Black women’s blood coagulates faster than that of white women” which then delays treatment for hemorrhages, all of which increase the risk of medical mistreatment. Additionally, most textbooks utilize a European-standardized set of illustrations for anatomy, which does not account for variations that occur with women of color across the world. This then increases unnecessary and potentially fatal interventions as variations from the norm are deemed “high risk”. Even many medical advocates assume biological predispositions for specific diseases are root causes rather than systemic discrimination. 

In Brazil, which has seen a rapid decline in most healthcare related outcomes, including direct maternal mortality indicators, racial discrimination still exists. It was noted that although “‘de facto’ legislation did not exist, “dejure” discrimination” is still a predominant cause of death; the Brazilian Ministry of Health estimated 75/100k deaths in 2018. As per Dr. Natalia Kanem, executive director of the U.N. Sexual and Reproductive Health Agency, 

“When a Black woman dies during childbirth, whether in São Paulo, Bogotá or New York, it’s often put down to her lifestyle or to individual failure: She didn’t get there in time to see the doctor or the nurse, she made poor life decisions, she was predisposed to certain medical conditions. And then the world moves on.”¹⁷

In the United Kingdom (UK), where pregnancy or childbirth deaths are considered rare, racial disparity statistics show that “black and brown women” are over 2 times more likely to die than white women. One Indian woman from North London said that even though she knew something was wrong, and actually had developed sepsis post labor, doctors refused to listen to her concerns until over 24 hours later -- an almost fatal mistake. A Black woman in Kent stated that doctors refused to examine her when she was bleeding during pregnancy, claiming that it was a urinary tract infection, and that she still “had four days till the end of [her] antibiotics course.” After repeated demands for examination, she was “immediately taken to hospital because of a serious bleed… and needed several blood transfusions,” narrowly avoiding death. 

Even as healthcare improves globally, discrimination creates disparities in treatment. Women of color are often ignored or misdiagnosed, attributing end results to biases -- both medical and cultural. Another form of discrimination more prevalent in developing nations is the assumption of unawareness -- leading healthcare personnel to ignore individuals they consider uneducated. Additionally, discrimination often occurs when a clear gender disparity is present, with both men and women treated poorly and almost shamed into not seeking help.

Education

The need for global education is not a new concept or developmental goal. However, less emphasis is placed on the effect that education -- for both men and women -- has on maternal mortality. Generally, the U.N states that

“Education improves health, while health improves learning potential. Education and health complement, enhance and support each other; together, they serve as the foundation for a better world”. 

Of course, it is important to note that the quantitative effects are dependent on the acknowledgement of endogeneity in the various testing models; even so, education is an important factor. Even in adverse conditions, there is a positive relationship -- while, as stated, the strength varies -- between maternal or general education and health service use. 

The causal effect was tested in Peru, as a country where maternal mortality has declined over 70% in 20 years; the author utilized a 1993 amendment to compulsory schooling laws as exogenous variation. The results were clear -- extending a woman’s schooling “reduced the probability of several maternal health complications at last pregnancy/birth, sometimes by as much as 29%” -- this has further positive effects on socio economic independence. While education is a global development goal, it may not be prioritized in all developing nations, so positing the connection between education and maternal mortality rates provides a direct improvement metric. 

A big change that female education provides is the understanding of anatomy and reproductive care, deemphasizing the previously stated stigmas and norms in favor of medical fact. Many health workers in rural areas believe that women are ignorant, increasing neglect or misdiagnosis, as found in a study conducted in Uganda. This process of shaming or ignoring those deemed to be less educated increases the likelihood of individuals not seeking medical care until critically necessary. Attempts at education also often fail to fit into existing systems of birth-related knowledge, which alienates individuals in societies that have traditional methods to assist in maternal care; providing biomedical information in a more understandable manner is necessary. 

Men & Gender Structures

On the tail of education comes mitigating the gender imbalance. Men are often kept out of the conversation, and are thus misinformed about reproductive healthcare. At the 1994 International Conference for Population and Development, it was strategized that involving men in maternal health would positively influence healthcare -- for both men and women. As actors with their own “right to healthcare and partners with a responsibility to support women's [health],” active involvement is critical for change. Even in countries that have policies relating to safe motherhood, all stakeholders, especially men, need to be involved; this includes emotional and physical support and advocacy. 

Culturally, it is often assumed that pregnancy is a “women’s issue,” and thereby men are excluded from conversation. However, patriarchal structures, a larger tangential issue, leaves men with decision-making authority, and they often “decid[e] how their partners use health services” A study by UNICEF found that “in Burkina Faso, Mali and Nigeria, almost 75% of women reported that husbands alone made decisions,” delaying access to maternal health services. Most are not “knowledgeable about complications that can occur during pregnancy and childbirth, impacting decision making” when emergencies occur. 

Several studies have linked the lack of male participation to a fear of social stigma. In Kenya, men reported that they would be “ridiculed and not seen as “men” if seen taking part in maternal services,” and that healthcare workers often renege on privacy in favor of participating in social gossip. Apart from the culture of shame, economic insecurity made them feel uncomfortable to attend maternal checkups and were thereby uninformed about situations that arose. Even if they personally felt inclined to be involved, social pressures restricted them. This relates back to the negative outcomes during pregnancy and childbirth, as the support systems for mothers are lacking. 

Violence

A slight deviation from cultural and institutional causes of maternal mortality, violence has an effect that must be briefly discussed. In the United States, homicide relating to pregnancy is the leading cause of death; the research on direct causality is limited but focused on socioeconomic factors and Intimate Partner Violence (IPV). Mortality ratios for pregnancy associated homicide, which is the “homicide of a woman during pregnancy or within 1 year of the end of pregnancy,” is higher than any of the obstetric causes (e.g. hemorrhage, infection, etc)^,. Most relate to IPV, which is higher in areas with institutionalized community violence and other structural factors like poverty and resource instability. 

Additionally, consistent exposure to violent contexts increases stress in mothers, which then leads to physical repercussions such as cardio metabolic dysfunction -- an indirect method of death due to violence. In Australia it was found that between 2-5% of women experience IPV during pregnancy, leading to worse “perinatal and maternal outcomes,” which includes preterm labor, hemorrhage, and perinatal death. As a non-institutional factor, the significant impact that violence has on maternal mortality speaks to the need for immediate policy changes. Although not a fundamentally altering policy, several researchers call for the need to screen pregnant women for IPV and institutionalize responses to safeguard them.  

Existing Policies & New Recommendations

Education

Of all of the critical issues stated, education is one of the most researched and acted upon. The United Nations Millennium Development Goals lists education as one of the most fundamentally altering milestones across the world; it can alleviate socioeconomic disparities and has links to increases in healthcare, female autonomy, and safety. A key fact is that girls’ education specifically helps women control their own fertility rates and also improves maternal health. It’s estimated that even one extra year of schooling for 1,000 women can prevent 2 deaths. 

A U.N global review found that comprehensive sexual education (CSE) was one of the best policies for change. CSE covers a wide varied of age-appropriate information, from reproductive health to relationship management. The United Nations provides technical guidance on these voluntary programs, which vary across countries, and recommends that they are comprehensive, age-tailored, and comprehensive regarding sexual and reproductive health. These often provide critical information about family planning and information about autonomy and anatomy that are otherwise not discussed, thereby improving social development⁴⁰. However, less than 40% of countries have laws or policies that specifically address CSE, as most of the work is done by external groups or is informal. Even in countries where CSE is recognized, significant gaps remain in legislation, it’s often underfunded in education systems, and data is lacking on how well its actually being covered in curriculum or through social work. 

Stigma and cultural practices, as well as political influence, also hinder real progress. It is difficult to encourage members of societies that believe in traditional healthcare or with strongly enforced norms to participate in these programs. The Senior Programme Specialist in Health Education at UNESCO, Joanna Herat, said that, “despite the increased political will, there remained a significant gap between the many global and regional policies in place and the implementation on the ground,” and support from communities is essential but lacking. 

A recommendation here is to rework the method of education. Rather than providing an entirely new “handbook” that aggressively attempts to insert itself into communities, awareness should work with traditional methods as a supplement. For example, in Guatemala, a key issue is not that families cannot understand biomedical information, but that “this information fails to fit into an already existing social system of understanding birth and birth-related knowledge” Incorporating traditional knowledge and supplementing it with “modern” reproductive care can help individuals recognize signs and understand the entire process of pregnancy without feeling pressured to lose tradition or cultural sensitivities. Destigmatization and reducing misinformation is key here, rather than “scrapping” longlasting and traditionally sensitive methodologies.

Additionally, CSE should move beyond voluntary multilateral or social group work, and should be implemented as a legal framework that directly impacts education from the start. While this may face resistance both politically and socially, unless CSE is institutionalized globally -- and based on medical fact, not other factors -- this issue will not be solved. Reformation at an international level is the only way to ensure that education is prioritized and stigma and discrimination decrease, thereby reducing maternal mortality.

Male involvement

Several studies and policies have been implemented to get men more involved in maternal care. One randomized control trial (RCT) in Nepal reported “women who received education with husbands during antenatal care sessions were more likely to make birth preparations and attend postnatal visits compared to the control group women”. It’s been observed that involving men in birth planning and complication readiness was “positively associated with knowledge of obstetric danger signs during pregnancy, labor and postpartum period”. Men must be acknowledged as part of the process, as “agents of positive change with the ability to transform underlying gendered constraints on health”. However, these policies often fail due to stigma and deep gender norms, as well as a lack of a space for men to address their own reproductive health. The separation of genders creates disconnect and doesn’t accommodate the critical nature of male reproductive education -- which then translates into unhealthy relationships and a lack of willingness to support female health. 

As such, a recommendation is to build on education reforms and focus on a community approach to incorporate men into maternity care. One system that should be modeled across the world is based on a program in Mozambique called “Male Champions,” which utilized male healthcare workers to help redefine community norms. This method allowed for familiarity and comfort in healthcare settings as well as an increased attentiveness to women’s care needs -- which then created a larger environment of trust to and from patients and healthcare workers. A similar program showed positive results in Bangladesh, which allowed men to recognize danger signs and advocate for maternal care -- thereby mitigating factors for mortality. Although not an entirely new policy, it is recommended that these methods become mainstream and part of intergovernmental agencies’ approaches to reproductive health -- rather than a tunneled method that excludes men from the conversation. 

Traditional Birth Attendant Subsidization

The last recommendation is to subsidize traditional pregnancy healthcare methods, such as doulas and midwives, globally. Given that several communities culturally prefer more “traditional” birthing practices and pregnancy support, rather than forcing more western or hospital-based healthcare, it would be beneficial to increase the number of skilled traditional birth attendants. The issue with mortality is that it’s not entirely about how to save lives in a literal sense, but rather foundational reforms in sociocultural practices and gender imbalances compounded with educational lag. Given that traditional birth attendants are often inexpensive, especially in rural areas, many prefer to utilize this route -- but a critical issue is that many traditional attendants are “neither skilled nor equipped to handle complicated cases – and if they are not effective, they can never be cost-effective”. Additionally, States may be hesitant to invest in providing training to traditional attendants over increasing facility capabilities. Yet it stands to reason that if communities are more comfortable with midwives, doulas, or other attendants, then utilizing them to benefit healthcare outcomes would be a worthwhile investment.

Subsidization and budgeting for proper training can help stop the major causes of maternal death during and post birth while also remaining a cost effective and culturally normalized method. Doulas are known, as tracked in the United States, to improve outcomes for low income areas and communities of color. Skilled attendants can be viewed more positively than healthcare facilities, as they often merge biomedical knowledge with traditional practices, creating an environment that is more comforting and encouraging of normative change. In regions with poor facility care, irrespective of education or cultural aversion, research has found that “women may be acting rationally in selecting home delivery given the binding constraints on good quality care,” thereby safeguarding themselves from mortality. Institutionalized investment in skilled traditional birth assistants can thus decrease the delays in accessing quality obstetric care, provide biomedical education, and potentially reform norms through personalized bonds and the integration of traditional methodologies. 

Conclusion

Maternal mortality is a facet of the larger issues surrounding global reproductive health; policy recommendations can spark progress across intersecting issues. Inclusive education and communication will both redefine gender norms and motivate advocacy for comprehensive healthcare within communities. While violence is not institutionalized like other factors, it can be mitigated by the recommendations above due to the redefinition of normative behaviors. Additionally, subsidizing and training traditional birth attendants provides a more economic and socially accessible means to increasing obstetric care. This then decreases the risks of poor birth outcomes, and can help mitigate stigmas and misinformation from a more “communally integrated” way. Acknowledging that these actions are just the start, and that political will and economic factors also play a part in determining the solution's effectiveness, is important. Yet, the ground up focus of these recommendations is a baseline for institutionalized reforms and developmental growth as a whole.

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