By Loubna Belaid and Valery Ridde
Every day approximately 830 mothers around the world die due to pregnancy and childbirth complications. Most of these are preventable deaths. That's why improving childbirth outcomes was a critical issue at the recent G7 Health Ministers meeting attended by Canada.
We know where it's happening. The number of mothers that die relative to the number of births -- what's called the mortality maternal ratio -- is much higher in low-income countries. In 2015, the maternal mortality ratio in low-income countries was estimated at 239 per 100,000 births compared to 12 per 100,000 in high-income countries.
In fact, maternal mortality can be much higher than this in specific countries within low-income countries due to dramatic disparities in quality and access to services. For instance, in South Sudan the maternal mortality ratio is estimated at 789 maternal deaths per 100,000 births.
By comparison, in Canada, the mortality maternal ratio was 7 per 100,000 births in 2015, though with significantly higher rates among our indigenous populations.
We know that improving access to health care services is important for pregnant women. In fact, this is number five of The Millennium Development Goals adopted by the United Nations and 23 international organizations, including Canada, in 2000.
Canada supported that goal by spearheading the 2010 MUSKOKA initiative, where G8 countries invested $7.3 billion to reduce maternal, neonatal and child mortalities globally. Canada itself invested $1.1 billion to the cause.
But what if access to healthcare services isn't enough? What if expecting mothers, despite the risks they see around them, reject healthcare services offered to them?
That's what researchers discovered in a meta-analysis on the barriers expecting mothers face when seeking medical care in low and middle income countries.
Studies reported women being concerned with or having previously experienced practices in healthcare facilities that can be filed under the official heading "disrespect and abuse." For example, care in hospitals and health facilities was often associated with physical and verbal abuse, non-consensual care, discrimination, neglectful care, lack of privacy and even detention against the patients' will.
The analysis found hospital facilities were perceived to be providing too many invasive interventions, such as unnecessary vaginal examinations, that they were insensitive to privacy issues and that they took away women's control over the birthing process.
Many complained of a lack of supportive attendants at birth during a hospital delivery, some experienced long delays for care, and some had a fear of cutting (from episiotomy or caesarean section). Some women described health providers as verbally abusive, lacking compassion, or even physically abusive during delivery. Some feared compulsory HIV testing or HIV-status disclosure. And some feared stigmatization because of their unwed status.
These issues of cultural disconnect and disrespect and abuse are matters of quality of care -- which, globally, haven't had enough attention -- but are important for improving maternal outcomes. In fact, researchers have found that improving the quality of care is essential for improving maternal outcomes.
Around the world there are global civil and professional movements to promote childbirth based on respect and dignity. For example, the White Ribbon Alliance convenes individuals, NGOs, professional associations, government entities, youth, community leaders, academics and donor agencies to promote every woman's right to a safe birth.
Canada has already committed 20 projects on the ground, with Canadian researchers working alongside African researchers and policy makers to improve access and quality of care to expecting mothers and babies.
But Canada can -- and must -- do more. Canada can direct policies and funding at tackling disrespect and abuse at health facilities. We can insist on sensitization training for global health students and NGO workers. We can encourage more awareness on the issue for policy makers and health professionals working in the field. We can support more research on evidence-based policies to inform our goals.
Of course, Canada should always work with local practitioners, researchers and policy makers to avoid replicating colonial mistakes of the past. And quality of care should be an integral part of our broader commitment to addressing other barriers to healthcare, such as access, transportation, education and more.
The Trudeau government has said that it wants Canada to take a leadership role in global health, including infant and maternal mortality. Addressing maternal barriers to health care -- including quality of care -- will help the work we're doing go a lot farther.
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The world’s second smallest country is also one of the richest, with more millionaires and billionaires per capita than any other country in the world. It also seems like a dream to give birth in Monaco: The antenatal and postpartum care sounds downright magical, and the country has some of the lowest infant mortality rates on earth. So what gives on the low birth rate, at just 6.72 births per 1,000 people? One theory is that the population is considerably older than the global median, which means lower fertility rates. Couple advanced age with the higher education typical of the people of Monaco, and you’re looking at fewer babies for this densely populated nation.
The declining birth rate in Japan, at 8.4 births per 1,000 people, is actually cause for alarm: The country’s population has dropped by nearly a million people over the past five years, when you compare the low birth rate with the high death rate. This is such an appalling stat that the Japanese government is taking measures to bolster their population in years to come, including major changes to their policies affecting women, children and seniors. Other reasons for the decline include the climbing cost of raising a family, the number of women in the workforce and the older average age of marriage.
Just 8.2 babies were born per 1,000 people over the past five years in this European nation, putting it neck and neck with Japan. Experts are conflicted as to why the birth rate is dropping, but myriad theories include more women focusing on career before family, the trend toward later-in-life childbearing, difficulty accessing child care, and confusing social policies as reasons for the downturn.
Declining birth rates are actually a concern across Asia but South Korea, with a birth rate of 8.55 births per 1,000 people and its steep decline of people under the age of 40, is in danger of becoming one of the oldest countries, population-wise, in the world. Like other countries, extreme work culture and more women in the labour force are to blame, but lack of immigration is also a factor. Other countries can supplement low birth rates with immigration, but South Korea is notoriously difficult when it comes to permitting naturalized citizens.
At just 8 births per 1,000 people, Italy is in a population collapse. There were just 488,000 births in the country in 2015, which is lower than any year since the modern state was founded in 1861. Officials are keeping close tabs on the situation and are offering up potential benefits for growing families. The policy changes include a baby bonus (which was not well-received, for its small amount and the limited number of kids it covers) and a national Fertility Day campaign urging young women to listen to their biological clocks, and young men to avoid smoking for the health of their sperm. Italy’s declining population can be chalked up to high unemployment numbers, lower wages for women, and inadequate childcare and social services.