Maternal health:

Data from 1990 to 2017 show that a quarter of all women who died while giving birth in low- and
middle-income countries had undergone cesarean section. “The outcomes for women in low and
middle-income countries are far worse than we expected,”. “In sub-Saharan Africa, one in 100 women
who has a cesarean section will die - 100 times more than women in the UK. The outcomes for their
babies are even worse, with eight per cent not surviving longer than a week.”

The risk for stillbirth and perinatal deaths was similarly higher in low- and middle-income countries.
The overall rate of stillbirth in babies born by caesarean section was 56.6 per 1000 caesarean, with
the highest rates in sub-Saharan Africa (82.5 per 1000). The perinatal death rate was 84.7 per 1000
caesarean sections, with the highest rates in the Middle East and North Africa (354.6 per 1000)
followed by sub-Saharan Africa (100.4 per 1000).

Moreover, women undergoing emergency caesarean section in low- and middle-income countries
were twice as likely to die than those delivering by elective caesarean section, and when caesarean
section was performed in advanced labour at full dilation of the cervix (second stage). The odds
increased 12-fold compared to caesarean section in the first stage. Perinatal deaths increased 5-fold
with emergency vs elective caesarean sections, and 10-fold when undertaken in the second vs first
stage of labour.

A third of all deaths following caesarean section were attributed to postpartum haemorrhage (32%),
19% to pre-eclampsia, 22% to sepsis, and 14% to anaesthesia related causes. This is in line with an
increased body of evidence warning about caesarean section as a primary cause of postpartum
haemorrhage and underscores gaps in resource and skills to manage massive obstetric haemorrhage,
and a need for specific training in this area.

Overuse and under use of caesarean section coexist

Every year, 300 000 women die during childbirth, 99% of whom are from low- and middle-income
countries. Timely access to caesarean section when needed is required for safe childbirth, but ‘too
little, too late,’ or ‘too many, too soon’ are part of a problem and not a solution. While many women
in need of caesarean sections still do not have access to caesarean section particularly in low
resource settings, many others undergo the procedure unnecessarily, for reasons which are not
medically justified.
Caesarean section context

There are many complex reasons for the rise in caesarean section rates, and these vary widely
between and within countries. Before implementing any intervention to reduce these procedures,
research should be undertaken to identify and define the reasons behind the increase in caesarean
sections in particular settings, as well as the locally relevant determinants of caesarean births, and
the views and cultural norms of women and health care providers.

A call to improve access to safe surgery, appropriate intrapartum care and training
Caesarean birth is associated with short- and long-term risks that can extend many years beyond
delivery; affect the health of women and their children, as well as future pregnancies. These risks are
higher in women with limited access to comprehensive obstetric care. WHO recommends that
caesarean section should only be conducted when medically necessary.

Quality of care is of particular concern in low- and middle-income countries. Researchers of the
study are calling on policy-makers and health care professionals to promote appropriate use of the
procedure, improve access to quality surgery and intrapartum care, and improve services on
neonatal resuscitation to help improve outcomes for babies.

The training is needed in decision making to reduce unnecessary caesarean sections, and in
appropriate intrapartum care including instrumental deliveries to reduce caesarean sections
performed in the second stage of labour, which carry greater risk.

WHO response

Improving maternal health is one of WHO’s key priorities. WHO works to reduce maternal
mortality by increasing research and evidence, providing evidence-based clinical and programmatic
guidance, setting global standards, and providing technical support to Member States.

Key facts:

 Every day, approximately 830 women die from preventable causes related to pregnancy and
childbirth.
 99% of all maternal deaths occur in developing countries.
 Maternal mortality is higher in women living in rural areas and among poorer communities.
 Young adolescents face a higher risk of complications and death as a result of pregnancy than
other women.
  Skilled care before, during and after childbirth can save the lives of women and newborn
babies.
 Between 1990 and 2015, maternal mortality worldwide dropped by about 44%.
 Between 2016 and 2030, as part of the Sustainable Development Goals, the target is to reduce
the global maternal mortality ratio to less than 70 per 100 000 live births.

Maternal mortality:
Maternal mortality is unacceptably high. About 830 women die from pregnancy- or
childbirth-related complications around the world every day. It was estimated that in 2015, roughly
303 000 women died during and following pregnancy and childbirth. Almost all of these deaths
occurred in low-resource settings, and most could have been prevented.

In sub-Saharan Africa, a number of countries halved their levels of maternal mortality since 1990. In
other regions, including Asia and North Africa, even greater headway was made. Between 1990 and
2015, the global maternal mortality ratio (the number of maternal deaths per 100 000 live births)
declined by only 2.3% per year between 1990 and 2015. However, increased rates of accelerated
decline in maternal mortality were observed from 2000 onwards. In some countries, annual declines
in maternal mortality between 2000–2010 were above 5.5%.

The Sustainable Development Goals and the Global Strategy for Women's,
Children’s and Adolescents’ Health

Seeing that it is possible to accelerate the decline, countries have now united behind a new target to
reduce maternal mortality even further. One target under Sustainable Development Goal 3 is to
reduce the global maternal mortality ratio to less than 70 per 100 000 births, with no country having
a maternal mortality rate of more than twice the global average.

Where do maternal deaths occur?

The high number of maternal deaths in some areas of the world reflects inequities in access to health
services, and highlights the gap between rich and poor. Almost all maternal deaths (99%) occur in
developing countries. More than half of these deaths occur in sub-Saharan Africa and almost one
third occur in South Asia. More than half of maternal deaths occur in fragile and humanitarian
settings.
The maternal mortality ratio in developing countries in 2015 is 239 per 100 000 live births versus 12
per 100 000 live births in developed countries. There are large disparities between countries, but also
within countries, and between women with high and low income and those women living in rural
versus urban areas.

The risk of maternal mortality is highest for adolescent girls under 15 years old and complications in
pregnancy and childbirth is a leading cause of death among adolescent girls in developing countries.

Women in developing countries have, on average, many more pregnancies than women in developed
countries, and their lifetime risk of death due to pregnancy is higher. A woman’s lifetime risk of
maternal death the probability that a 15 year old woman will eventually die from a maternal cause is
1 in 4900 in developed countries, versus 1 in 180 in developing countries. In countries designated as
fragile states, the risk is 1 in 54; showing the consequences from breakdowns in health systems.

Why do women die?

Women die as a result of complications during and following pregnancy and childbirth. Most of
these complications develop during pregnancy and most are preventable or treatable. Other
complications may exist before pregnancy but are worsened during pregnancy, especially if not
managed as part of the woman’s care. The major complications that account for nearly 75% of all
maternal deaths are:

 severe bleeding (mostly bleeding after childbirth)

 infections (usually after childbirth)
 high blood pressure during pregnancy (pre-eclampsia and eclampsia)
 complications from delivery
 unsafe abortion.

The remainder are caused by or associated with diseases such as malaria, and AIDS during
pregnancy.

How can women’s lives be saved?

Most maternal deaths are preventable, as the health-care solutions to prevent or manage
complications are well known. All women need access to antenatal care in pregnancy, skilled care
during childbirth, and care and support in the weeks after childbirth. Maternal health and newborn
health are closely linked. It was estimated that approximately 2.7 million newborn babies died in
2015, and an additional 2.6 million are stillborn. It is particularly important that all births are
attended by skilled health professionals, as timely management and treatment can make the
difference between life and death for both the mother and the baby.

Severe bleeding after birth can kill a healthy woman within hours if she is unattended. Injecting
oxytocin immediately after childbirth effectively reduces the risk of bleeding.

Infection after childbirth can be eliminated if good hygiene is practiced and if early signs of infection
are recognized and treated in a timely manner.

Pre-eclampsia should be detected and appropriately managed before the onset of convulsions
(eclampsia) and other life-threatening complications. Administering drugs such as magnesium
sulfate for pre-eclampsia can lower a woman’s risk of developing eclampsia.

To avoid maternal deaths, it is also vital to prevent unwanted and too-early pregnancies. All women,
including adolescents, need access to contraception, safe abortion services to the full extent of the
law, and quality post-abortion care.

Why do women not get the care they need?

Poor women in remote areas are the least likely to receive adequate health care. This is especially
true for regions with low numbers of skilled health workers, such as sub-Saharan Africa and South
Asia. Globally in 2015, births in the richest 20 per cent of households were more than twice as likely
to be attended by skilled health personnel as those in the poorest 20 per cent of households (89 per
cent versus 43 per cent). This means that millions of births are not assisted by a midwife, a doctor or
a trained nurse.

In high-income countries, virtually all women have at least four antenatal care visits, are attended by
a skilled health worker during childbirth and receive postpartum care. In 2015, only 40% of all
pregnant women in low-income countries had the recommended antenatal care visits.

Other factors that prevent women from receiving or seeking care during pregnancy and childbirth
are:

 poverty
  distance
 lack of information
 inadequate services
 cultural practices.

To improve maternal health, barriers that limit access to quality maternal health services must be
identified and addressed at all levels of the health system.

WHO response:

Improving maternal health is one of WHO’s key priorities. WHO works to contribute to the
reduction of maternal mortality by increasing research evidence, providing evidence-based clinical
and programmatic guidance, setting global standards, and providing technical support to Member
States.

In addition, WHO advocates for more affordable and effective treatments, designs training materials
and guidelines for health workers, and supports countries to implement policies and programmes and
monitor progress.

During the United Nations General Assembly 2015, in New York, UN Secretary-General Ban
Ki-moon launched the Global Strategy for Women's, Children's and Adolescents' Health, 2016-2030.
The Strategy is a road map for the post-2015 agenda as described by the Sustainable Development
Goals and seeks to end all preventable deaths of women, children and adolescents and create an
environment in which these groups not only survive, but thrive, and see their environments, health
and wellbeing transformed.

As part of the Global Strategy and goal of Ending Preventable Maternal Mortality, WHO is working
with partners towards:

 addressing inequalities in access to and quality of reproductive, maternal, and newborn health
care services;
 ensuring universal health coverage for comprehensive reproductive, maternal, and newborn
health care;
 addressing all causes of maternal mortality, reproductive and maternal morbidities, and
related disabilities; and
  strengthening health systems to collect high quality data in order to respond to the needs and
priorities of women and girls; and
 ensuring accountability in order to improve quality of care and equity.

Preterm delivery:

Important factors:

 Every year, an estimated 15 million babies are born preterm (before 37 completed weeks of
gestation), and this number is rising.
 Preterm birth complications are the leading cause of death among children under 5 years of
age, responsible for approximately 1 million deaths in 2015 (1).
 Three-quarters of these deaths could be prevented with current, cost-effective interventions.
 Across 184 countries, the rate of preterm birth ranges from 5% to 18% of babies born.

Definition:
Preterm is defined as babies born alive before 37 weeks of pregnancy are completed. There are
sub-categories of preterm birth, based on gestational age:

 extremely preterm (less than 28 weeks)

 very preterm (28 to 32 weeks)
 moderate to late preterm (32 to 37 weeks).

Induction or caesarean birth should not be planned before 39 completed weeks unless medically
indicated.

Problem:

An estimated 15 million babies are born too early every year. That is more than 1 in 10 babies.
Approximately 1 million children die each year due to complications of preterm birth. Many
survivors face a lifetime of disability, including learning disabilities and visual and hearing
problems.

Globally, prematurity is the leading cause of death in children under the age of 5 years. And in
almost all countries with reliable data, preterm birth rates are increasing.
Inequalities in survival rates around the world are stark. In low-income settings, half of the babies
born at or below 32 weeks (2 months early) die due to a lack of feasible, cost-effective care, such as
warmth, breastfeeding support, and basic care for infections and breathing difficulties. In
high-income countries, almost all of these babies survive. Suboptimal use of technology in
middle-income settings is causing an increased burden of disability among preterm babies who
survive the neonatal period.

Solution:

More than three quarters of premature babies can be saved with feasible, cost-effective care, such as
essential care during child birth and in the postnatal period for every mother and baby, provision of
antenatal steroid injections (given to pregnant women at risk of preterm labour and under set criteria
to strengthen the babies’ lungs), kangaroo mother care (the baby is carried by the mother with
skin-to-skin contact and frequent breastfeeding) and antibiotics to treat newborn infections. For
example, continuity of midwifery-led care in settings where there are effective midwifery services
has been shown to reduce the risk of prematurity by around 24%.

Preventing deaths and complications from preterm birth starts with a healthy pregnancy. Quality care
before, between and during pregnancies will ensure all women have a positive pregnancy experience.
WHO’s antenatal care guidelines include key interventions to help prevent preterm birth, such as
counselling on healthy diet and optimal nutrition, and tobacco and substance use; fetal measurements
including use of ultrasound to help determine gestational age and detect multiple pregnancies; and a
minimum of 8 contacts with health professionals throughout pregnancy to identify and manage other
risk factors, such as infections. Better access to contraceptives and increased empowerment could
also help reduce preterm births.

Why does preterm birth happen?

Preterm birth occurs for a variety of reasons. Most preterm births happen spontaneously, but some
are due to early induction of labour or caesarean birth, whether for medical or non-medical reasons.

Common causes of preterm birth include multiple pregnancies, infections and chronic conditions
such as diabetes and high blood pressure; however, often no cause is identified. There could also be a
genetic influence. Better understanding of the causes and mechanisms will advance the development
of solutions to prevent preterm birth.
Where and when does preterm birth happen?

More than 60% of preterm births occur in Africa and South Asia, but preterm birth is truly a global
problem. In the lower-income countries, on average, 12% of babies are born too early compared with
9% in higher-income countries. Within countries, poorer families are at higher risk.

WHO response:

In 2012, WHO and partners published a report Born too soon: the global action report on preterm
birth that included the first-ever estimates of preterm birth by country.

WHO is committed to reducing the health problems and lives lost as a result of preterm birth:

 Working with Member States and partners to implement Every newborn: An action plan to
end preventable deaths adopted in May 2014 in the framework of the UN
Secretary-General’s Global strategy for women’s and children’s health;
 Working with Member States to strengthen the availability and quality of data on preterm
births;
 Providing updated analyses of global preterm birth levels and trends every 3 to 5 years;
 Working with partners around the world to conduct research into the causes of preterm birth,
and test effectiveness and delivery approaches for interventions to prevent preterm birth and
treat babies that are born preterm;
 Regularly updating clinical guidelines for the management of pregnancy and mothers with
preterm labour or at risk of preterm birth, and guidelines on the care of preterm babies,
including kangaroo mother care, feeding babies with low birth weight, treating infections and
respiratory problems, and home-based follow-up care (see WHO 2015 recommendations on
interventions to improve preterm outcomes);
 Developing tools to improve health workers’ skills and assess the quality of care provided to
mothers at risk of preterm delivery and preterm babies; and
 Supporting countries to implement WHO's antenatal care guidelines, aimed at reducing the
risk of negative pregnancy outcomes, including preterm births, and ensuring a positive
pregnancy experience for all women.

Guidelines to improve preterm birth outcomes

WHO has developed new guidelines with recommendations for improving outcomes of preterm
births. This set of key interventions can improve the chances of survival and health outcomes for
preterm infants. The guidelines include interventions provided to the mother – for example steroid
injections before birth, antibiotics when her water breaks before the onset of labour, and magnesium
sulfate to prevent future neurological impairment of the child – as well as interventions for the
newborn baby – for example thermal care, feeding support, kangaroo mother care, safe oxygen use,
and other treatments to help babies breathe more easily.

WHO recommendations on interventions to improve preterm birth outcomes