Mother’s Day: Maternal Health

Blog Centro Elena Cornaro

by Lucia Lupotti

In honor of Mother’s Day, we would like to share information about maternal health and its implications.

What is Maternal Health?

The World Health Organization defines maternal health as the health of a mother during pregnancy, childbirth and the postnatal period. Some doctors define the postnatal period as 42 days post-pregnancy, while others would like to extend it to one year post-pregnancy. The mother should have positive experiences and be guided during each stage by medical personnel, when necessary. However, this is not always the case.

It is reported that a lot of the causes of maternal-health-related deaths can be prevented. The Sustainable Development Goals (SDG) 2016-2030 have specifically called on European states to act “with the aim of eliminating avoidable maternal and infant deaths: the first step being to improve data monitoring and reporting so that every woman, fetus or newborn who dies following birth does not go unnoticed.” In general, SDG 3 focuses on ensuring healthy lives and promoting well-being for all at all ages.

The Life Course Approach

An approach to studying maternal health and other factors of livelihood is the life course approach, which also supports SDG 3 by providing a holistic view of people’s health and well-being at all ages. It refers to a person’s “physical and mental health and wellbeing being influenced throughout life by the wider determinants of health.” These include a wide range of social, economic and environmental factors, alongside behavioral risk factors which often cluster in the population, reflecting real lives. Furthermore, these factors can be classified as protective factors or risk factors. Considering the upbringing of a mother is important because it can impact the birth of her child and their livelihood; even understanding her lineage and experiences of her grandmother and mother are key factors. Adopting the life course approach essentially identifies the opportunity where risk factors can be minimized and protective factors can be enhanced. These opportunities are then followed through with evidence-based interventions at “important life stages, from the perinatal period through early childhood to adolescence, working age, pre-conception and the family-building years, and into older age.” This encompasses many factors such as the urban environment, housing, the overall health of a mother, socio-economic status, access to resources, quality of the hospital, whether a mother can take time off of work, and more. This life course approach is specifically concerning the latent effects which are related to how the early life environment affects adult health independent of intervening exposure. Thus, interventions and improved quality of life for a mother can largely impact the life-trajectory of her children.

There are many social, economic, and environmental factors which influence the risk of maternal mortality. This includes social determinants of health, “such asincome, education, and environmental exposures; access to high-quality health care with sufficient numbers of competent, skilled providers, equipment, and medication; gender norms that devalue women and girls and limit their access to sexual and reproductive health care; and external factors such as political instability, conflicts, and climate change.” These factors require intersectoral collaboration to improve maternal health and well-being at every stage. Hence proving the importance of understanding intersectionality and the application of the life course approach for the amelioration of maternal health and essentially child health.

Gender Norms and the Devaluation of Women and Girls

Across the world, gender norms which devalue women and girls often impact their access to sexual and reproductive health care. Some of these gender norms include stigmatization, social exclusion of girls from sexual and reproductive health education services, the strong decision-making power of family members over contraceptive use and women’s adherence to pregnancy monitoring and access to supervised delivery, the responsibility women and girls have for the health of new-borns, and many more. A theory applied to help understand this topic is intersectional feminist theory, which “posits that multiple social identities and experiences of social marginalization (ie, subordination and exclusion based on social characteristics such as gender, race or ethnicity, class or caste, social position, etc) intersect to create compounded privilege or marginalization for individuals.” For example, in the US, there are many states which do not want courses to cover sexual or reproductive health. Another example stems from child marriage. Child marriage greatly limits women and girls’ rights to health, education, and presents many barriers in decision making, autonomy, and more. It also exposes girls and women to higher rates of domestic violence. Additionally, child marriage likely results in young pregnancies, of which are one of the leading causes of death amongst girls ages 15 to 19. Furthermore, it is important to acknowledge how interactions within and between the health system and community are influenced “by restrictive gender norms and inequalities (eg, power and trust), affecting the strength, efficiency, and health impact of health system components and the system as a whole.” In other words, restrictive gender norms and inequalities translate into the health system, harming the health of women, the community, and the functioning of the wider health system.

In the USA

The World Health Organization defined a maternal death as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes." The definition of maternal death is being debated, leaning towards including up to a year after birth due to complications that can arise even after 42 days of termination of pregnancy. The 42 days mentioned here refer to the 6 weeks after pregnancy that a woman’s body is supposed to be back to ‘normal’, but this is not always the case. Furthermore, every year in the U.S., hundreds of people die during pregnancy or in the year after, and thousands more "have unexpected outcomes of labor and delivery with serious short- or long-term health consequences," per the Centers for Disease Control and Prevention (CDC). All deaths related to pregnancy are tragic, "especially because more than 80% of pregnancy-related deaths in the U.S. are preventable," the CDC noted.

Institutional change is very important to help reduce maternal mortality in the US. Broader change is needed, as Dr. Rainford says, “while women can play a role, I think the responsibility is largely in the hands of institutions to improve the health care they deliver to pregnant women.” Dr. Rainford studies the way intersectionality between race, ethnicity, and socio-economic standing play an important role in maternal mortality. Along these lines, Dr. Rainford states that, “even a low-risk Black woman entering pregnancy is significantly more likely to die than a similarly low-risk white woman.” Black pregnant women, in particular, suffer the worst maternal health disparities. In 2021, “Black women were nearly three times more likely to die from a pregnancy-related cause than white women, according to data from the US National Vital Statistics System. The maternal mortality rate for Black women was 69.9 deaths per 100,000 live births, which is 2.6 times the rate for their white counterparts.” Furthermore, “high-income non-Hispanic Black mothers have worse maternal and infant health outcomes than low-income non-Hispanic white mothers, which suggests a system failure rather than a woman not taking care of her health.”

In the European Union

Currently, there is a strong push from the European Institute of Women’s Health (EIWH) to promote gender equality in health institutions. Their opinion piece from June 2023, began with some facts such as: “In the EU 80% of care is provided informally (unpaid) and 75% of informal carers are women; Women are under-represented in medical research; and 500,000 women in Europe do not have access to care during the first months of pregnancy.”

With the European Parliament Elections nearing, the political manifesto of the EIWH calls for an EU Strategy for Women’s Health. The political manifesto explains that such a strategy would ensure that women’s health remains a policy and research priority. It would also “address the societal challenges that lead to health disparities; improve data collection and analysis; harmonize current legislation; and ensure that women’s voices and needs are embedded in all EU policies.”

Young women’s health is an under-researched, under-resourced and often overlooked area of healthcare, and a life-course approach is necessary to fully understand women’s health and potential complications that could arise. Thus, this approach must be implemented in research and at the policy level. This is to be accompanied with effective monitoring and evaluation measures, where substantial progress can be made on gender equality in health in the EU.

In Italy

The Italian Obstetric Surveillance System (ItOSS) collects and disseminates information on severe maternal morbidity and mortality. Since 2017, the surveillance system of maternal mortality, coordinated by the Istituto Superiore di Sanità (ISS), has been collecting comprehensive and reliable data on maternal mortality in 15 Italian regions (Valle D’Aosta, Piedmont, Lombardy, Veneto, Friuli Venezia Giulia, Emilia-Romagna, Marche, Umbria, Toscana, Lazio, Campania, Puglia, Calabria, Sicily, Sardinia, the Autonomous Province of Trento and the Autonomous Province of Bolzano), accounting for 94,7% of total births in Italy. The ItOSS works to promote actions for the dissemination of clinical practices that have been proved to be effective and safe at the regional and national levels. Many projects, collaborations and research are done through the ItOSS. In Italy, the ItOSS surveillance has detected a significant increase in the risk of maternal mortality for women of non-Italian citizenship, in particular for those of Asian ethnicity.

In 2023, thanks to the integration of various health flows including data from the National Outcomes Plan (PNE), it was possible, for the first time in Italy, to estimate the Maternal Mortality Ratio (MMR) at a national level expressed from the ratio of maternal deaths detected within 42 days of pregnancy outcome per 100,000 live births. In the years 2011-2019 the national MMR was equal to 8.3 deaths per 100,000 live births with a strong difference by geographical area between 5.9 in the Centre, 7.7 in the North and 10.5 in the South. From 2011 to In 2019, a decrease in the trend of deaths was recorded, from 11 to 8.6 per 100,000 live births. Of the total cases detected within 42 days, the majority (55.1%) involved direct deaths, i.e. due to obstetric complications. Among these, obstetric hemorrhage ranks first in terms of frequency (37.1%) while deaths due to cardiac pathology during pregnancy, as in all countries with advanced economic development, are the leading cause of indirect maternal death in Italy.

Conclusion

Maternal health and mortality continue to be obstacles and realities faced by many women across the globe. While efforts are being made, many mothers still die in the process of pregnancy and after due to pregnancy-related deaths. Thus, efforts at each level of governance are necessary to continue to decrease the rate of maternal mortality. As seen, efforts from the United Nations Sustainable Development Goals, to the European Union, at the state-level, and within the provincial and local governments are essential for the development and implementation of resources, monitoring, and research in maternal health. Intersectionality holds an important impact on the health of women and their access to medical resources. While in the US non-Hispanic Black mothers face the highest rate of maternal mortality and complications, it has been reported that Italy is seeing an increase in mortality rates for Asian mothers. Institutional problems, many times regarding health care or facilities, affect mothers and their infant’s health. With the advancement of medicine, vaccinations, and awareness, and interventions at the institutional level, maternal health will continue to improve on a global level.

Sources:

https://data.unicef.org/topic/maternal-health/maternal-mortality/

https://www.yalemedicine.org/news/maternal-mortality-on-the-rise

Allocastic Load and its Impact on Health

https://www.epicentro.iss.it/materno/trend-mortalita-materna-2000-2020

https://www.epicentro.iss.it/itoss/SorveglianzaMortalitaMaterno

epicentro.iss.it/en/itoss/maternal-mortality-surveillance

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800813/

https://www.who.int/our-work/life-course

Health Matters

https://sdgs.un.org/goals/goal3#targets_and_indicators

https://www.who.int/health-topics/maternal-health#tab=tab_1