Every day, about 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 in which Canada participated.
We know where it’s happening. The number of mothers who die relative to the number of births — what’s called the maternal mortality 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 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 maternal maternal ratio was seven per 100,000 births in 2015, though with significantly higher rates among indigenous populations.
We know that improving access to health-care services is important for pregnant women. In fact, this is No. 5 of the Millennium Development Goals adopted by the UN 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 invested $1.1 billion in the cause.
But what if access to health-care services isn’t enough? What if expectant mothers, despite the risks they see around them, reject health-care services offered to them?
That’s what researchers discovered in a meta-analysis on the barriers expectant mothers face when seeking medical care in low- and middle-income countries.
Studies reported women being concerned with or having previously experienced practices in health-care 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, disrespect and abuse are matters of quality of care — which, globally, haven’t had enough attention — but are important. 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 to 20 projects on the ground, with Canadian researchers working alongside African researchers and policymakers to improve access and quality of care to expectant 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 policymakers 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 policymakers 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 health care, such as access, transportation and education.
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 further.
Loubna Belaid is a postdoctoral researcher at the University of Montreal’s School of Public Health. Valery Ridde is an adviser to EvidenceNetwork.ca and an associate professor of global health in the department of social and preventive medicine and the Research Institute of the University of Montreal School of Public Health.
