Chiara Milani
The reduction of maternal mortality and the promotion of the health and well-being of pregnant women and mothers are important objectives to achieve. Avoidable deaths are not exclusively due to the biomedical complications of pregnancy, childbirth and the post-natal period but, unfortunately even today, they are also the tangible manifestations of the prevailing determinants of maternal health and persistent inequalities in global health and socio-economic development. economic.
A recent series from the authoritative scientific journal Lancet, entitled “Maternal health in the perinatal period and beyond”, addresses the topic of maternal health with four papers. The first (1) – the subject of review in this post – outlines the proximal and distal determinants and exposure and risk factors associated with maternal mortality; It also deals with the relationship between these determinants and the phenomenon of ‘maternal mortality transition‘ (the change from a high mortality pattern to a low mortality pattern). This writing is linked to a recent post (2) which addressed the phenomenon of maternal mortality from the point of view of its numerical entity.
By establishing the Sustainable Development Goals (Sustainable Development GoalsSDGs), the international community had set itself the goal of achieving a maternal mortality rate of 70/100,000: a goal that remains elusive to date, if we consider that in 2020 it still stood at 223/100,000, with only two regions that have observed an improvement in the indicator since 2016 (Central and Southern Asia, Australia and New Zealand) (3). An element to pay attention to is that in large part these are preventable deaths and concentrated in groups in socio-economic conditions already disadvantaged and/or burdened by epidemics, wars or other health emergencies (4).
Historically, the topic has been approached by providing direct investments aimed at resolving biomedical causes and paying less attention to hidden determinants and how health services could be designed to implement effective interventions. in mitigating the effects of these determinants. Furthermore, the exclusive focus on mortality is limited to comprehensively address the broad topic of maternal health, on which there is increasingly agreement in the holistic and integrated approach, in terms of promoting health and well-being and an experience positive treatment (5, 6). Given the complex and multifaceted nature of the maternal health phenomenon, researchers have developed a framework that represents itmade up of two levels of interconnected factors: eco-social forces (super-determinants and social determinants of maternal health) and individual-level factors (which also include lifestyles) (Figure 1).
Taking the first level into consideration, it is ‘hidden forces‘ that influence the health and well-being of women before, during and after pregnancy (7): the characteristics of the biosphere, the biological aspects of the human species, the economic, political and cultural foundations of society (8, 9). It emerges that maternal health is the result of the combination of the biological and behavioral characteristics intrinsic to the human being, the effects of human interactions with the environment and the cultural, political and economic adaptations of a society. In particular, social determinants – i.e. the conditions in which a woman is born, raised, works and lives, as well as inequalities related to gender, income, level of education, ethnicity – are at the basis of inequalities in outcomes of maternal health. Individual and family level factors include age, pre-existing health conditions, exposure to environmental risk factors and domestic violence (10).
The following story, by way of example, allows us to introduce a further concept, that of ‘embodiment’.
“Let’s consider a woman born and raised in poverty with little access to education, income, access to healthy food, to contraceptives. At a certain age, as a pregnant multiparous woman, she faces severe bleeding after giving birth to a stillborn baby. Although she was given uterotonics, she survived the postpartum hemorrhage thanks to an emergency hysterectomy. However, she had to face a long convalescence which added to the pain of the loss of her son. Her family is further forced into poverty due to the huge out-of-pocket expenses due to specialist care for complications”.
Con ‘embodiment’ we are referred to as women’incorporate’ in the body and mind the interactions between their being, the context and internal and external forces, therefore between the different levels of determinants described previously (11). Consequently, specific factors that are associated with maternal mortality and morbidity are nothing more than a concrete expression of such determinants that can become complicated with the emergence of biomedical factors, which ultimately result in mortality.
Role of the health service
The health service plays a crucial role in configuring the incorporation of the determinants stated above, that is, it can modify the effect of the eco-social forces that result in unfortunate outcomes. Consequently, it is also a decisive protective factor, capable of neutralizing or limiting the effects of these risk factors.
It is clear that the quality of the health service and care is a fundamental attribute: in maternal health services it refers to sufficient human resources, infrastructure, efficient processes, raw materials.
Determinants of maternal health and transition in maternal mortality
Despite the still high maternal mortality rate (Mortal Maternity RateMMR), it should be remembered that the absolute number is gradually decreasing. It is possible to describe the trend of MMR according to a model that relates maternal mortality levels to social development, reproductive health indicators, biomedical causes, the organization and quality of healthcare and whose central hypothesis is that social development offers protection or limits the negative effect of proximal and distal determinants, so as to have a trend of reduction in maternal mortality (12).
4 phases are identified which describe relative patterns (associated with a level of MMR in different countries), although the mortality transition model describes a continuous process:
Phase 1 with a very high maternal mortality (MMR >= 500 per 100,000); Phase 2 with a high maternal mortality (MMR between 300 and 499); Phase 3 with an intermediate level maternal mortality (MMR 100-299); Phase 4 with low or very low maternal mortality (MMR The precise thresholds of the transition phases are arbitrary, as they aim to illustrate the path of social and health evolution of the different countries. However, these phases indicate the eco-social forces and levels of social development prevalent in that country and can be useful for exploring strategies to address maternal health issues. It should also be remembered that in the same country different phases can coexist.
Considering the characteristics of the different phases, the following elements emerge:
The progression towards higher phases with the reduction of the MMR is also associated with a tendency to decrease maternal neonatal mortality, fertility rate and risk of expenses for surgical assistance which lead to impoverishment. The reduction of the MMR is also associated with an increase in life expectancy , universal health coverage, skilled birth, access to antenatal care, human development index. The neonatal mortality rate shows a strong relationship with the MMR. Health system indicators, such asUniversal health coverage’ and birth attendance tend to be strongly associated with MMR. The association with MMR is less strong than other social indicators (such as the Gini index).
Table 1 shows the distribution of different transition phases by number of countries and by year in which maternal mortality estimates were reported.
Phase stratification aims to identify patterns of determinants that may be most relevant at each phase of the transition, to be used as a reference in the development of multisectoral strategies. The profound relationship between maternal health outcomes and modifiable and non-modifiable factors is often ignored in the definition of interventions due to the complexity of this relationship and the elements involved. If maternal health problems and disability are social issues and maternal mortality is a social tragedy, addressing it requires extensive actions that transcend biomedical causes alone (which manifest themselves at an advanced stage in the journey between a health condition and a terminal illness or death). These awarenesses rather require transversal actions, which aim at social development and gender equality and which assign a central role to the health service in this process.
Chiara Milani, medical specialist in Hygiene and Preventive Medicine, AUSL Tuscany Centre
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