Globally, more than 5.6 million women and newborns every year die during pregnancy, childbirth, or in the first month of life. Compounding the tragedy, 99% of the maternal deaths and 80% of the newborn deaths can be prevented with the right care.
BOSTON – Tennis star Serena Williams’ harrowing story of life-threatening complications after the birth of her daughter reminds us that childbirth is potentially deadly for any woman or newborn. Williams suffered a pulmonary embolism – a blood clot in her lung. After advocating for herself, she received the lifesaving care she needed. Millions of women around the world do not.
Every year, more than 5.6 million women and newborns die during pregnancy, childbirth, or in the first month of life. Low-quality care during the 48 hours around childbirth, in particular, is one of the greatest contributors to birth-related suffering and death. These deaths shatter families and communities. And, compounding the tragedy, they are almost entirely avoidable. Ninety-nine percent of the maternal deaths and 80% of the newborn deaths can be prevented with the right care.
We know what kills women and newborns around the time of childbirth. The biggest killers of women are hemorrhage, sepsis, obstructed labor, and eclampsia. For newborns, the main risks are asphyxia (difficulty breathing), prematurity, and infection. How to assess, treat, and prevent these causes of death has been known for decades. In many cases, simple steps like washing hands, warming the baby with skin-to-skin care, or treating high blood pressure would make all the difference.
Globally, childbirth has shifted from the home to health facilities where a skilled clinician could provide safer care. This should mean better care and better outcomes. In many places, however, encouraging women to deliver in health facilities, rather than at home, has not resulted in reduced mortality. In too many places, facilities are unable to provide even the most basic care – like monitoring a laboring woman’s blood pressure – and women face lack of privacy, unhygienic conditions, or even abuse by staff.
Progress on reducing maternal and newborn mortality and morbidity, it has become clear, requires improving and strengthening the capabilities and quality of care in primary care facilities that provide labor and delivery services. But how?
For the last three years, we ran one of the world’s largest maternal-newborn health trials in the Indian state of Uttar Pradesh to see if we could reduce deaths by improving the quality of care in frontline facilities. These facilities, where most local women give birth, each averaged 3-4 deliveries a day, most of which were conducted by nurses. In the average frontline facility, we found that proper hand washing was completed in less than 1% of deliveries, and only 25% of women received the right medication to prevent postpartum bleeding. Overall, 11 of 18 essential birth practices were missing.
To improve performance and outcomes, we didn’t punish or fire staff. The problems typically stemmed from lack of organization and coordination to make certain that staff had the supplies, training, and supervision they needed. No method had been proved to make a large-scale difference. But we had a theory that coaching teams to implement key practices would help. We trained a group of nurses and doctors to coach birth attendants and managers to deliver the vital basics found in the World Health Organization’s Safe Childbirth Checklist: proper supplies and steps to prevent infection, identification and treatment of high blood pressure to prevent eclampsia, and appropriate medication to prevent hemorrhage.
The result was significant progress, but still not quite enough. We confirmed marked improvement in care. Birth attendants who had been performing just seven of 18 known life-saving steps during childbirth now performed 13. We showed that it is possible to improve significantly the quality of care in low-resource settings. Yet the evidence showed that we needed to do more to achieve a large-scale reduction in mortality rates.
The effort can be difficult and discouraging. Effective health systems must be able to close nearly all gaps in care, including gaps in supplies and equipment, basic skills and capabilities, and communication and connections to higher-level health facilities for sick mothers and babies. The relationships between clinical leaders and frontline providers, and between providers and the families they serve, must be respectful and supportive. There are no shortcuts. This is true everywhere in the world, whether in Florida, where Williams delivered, or in Uttar Pradesh, where we ran the BetterBirth intervention.
How do we get to this standard? We think the answer is not likely to be fundamentally different from what we attempted. We need to put in place mechanisms to identify the gaps at each facility and coach leaders and staff in closing them. But, as we observed, while our basic checklist provided the targets for improvement and a tool for organizing and reminding people of key steps, more was needed to accelerate change, including financial resources, political will, and the dedication of leaders, providers, and the community to demand progress.
We are closer than we have ever been to closing the gaps that account for most maternal and newborn mortality. We know that complications arise in childbirth for women everywhere. The good news is that we know what is needed to make childbirth safer. To improve the health and wellbeing of mothers and their newborns, we must translate that knowledge into reality in every facility around the world.
Katherine Semrau is an assistant professor of medicine at Harvard Medical School.
Atul Gawande is a professor at the Harvard T.H. Chan School of Public Health.