It has been a week of contrasts. The world’s press has been focused on the safe birth of one tiny princess at the same time as hundreds of babies are being born into an earthquake-devastated Nepal. It is tempting to consider that neither of these two extremes have much real impact on the lives of the majority of families in the UK.
But it is against this backdrop that Save the Children’s 16th State of the World’s Mothers report was published. It extensively analyses a range of indicators of women’s and children’s health to rank the experience of being a mother in 179 countries.
This report is welcome not just because it highlights that the situation for mothers and babies is most desperate among the urban poor in the world’s poorest countries. It also reveals that, in cities around the world, the poorest urban children are at least twice as likely to die by the age of five as the richest urban children.
The UK is ranked 24th in the report’s list of the best and worst places in the world for mothers and babies, an improvement of just two places from last year. The country hasn’t appeared in the top ten since 2012.
The report suggests that women in the UK are around twice as likely to die as a result of childbirth than their counterparts in Denmark or Finland. In fact, data in the report suggests that the situation for women in the UK appears closer to that of women in Slovenia, Qatar and Serbia.
This report should be a wake-up call to politicians, policy makers and healthcare providers across the UK. But we already know why mothers in the UK die. The UK has had a well-established audit and enquiry into maternal deaths that has reported every three years since 1985, so we have good information on the reasons and circumstances in which UK mothers die in relation to childbirth.
The UK has seen a shift in the demographics of women who are becoming pregnant, with more women who have increased care needs giving birth than in previous generations. There are now many more older mothers, more obese women and more women whose own country of birth was outside the UK. These women are all at increased risk during pregnancy.
In addition, there are many more women with multiple health conditions who in previous generations would have been less likely to become pregnant. The most recent report into maternal deaths in the UK found that almost three quarters of the women who died had coexisting medical complications. However, as highlighted in the report, the majority of health issues disproportionately impact on poorer women and women living in the most disadvantaged communities.
So in a high-income country that is proud of its National Health Service and universal provision of maternity care, how can we ensure our mothers and babies fare as well as our European neighbours? Of course, we need to prioritise closing the gap between the richest and poorest in society. Improving education, nutrition and mental well-being of young women before they even become pregnant would go some way to improving the health of mothers and babies in the UK.
However, the quality of and access to maternity care must also be addressed. Within the UK, there has been longstanding and ongoing debate about who should provide maternity care, how often and in what location. If the health of mothers and babies is to be improved there is no room for professional rivalries or political grandstanding. Mothers and babies need skilled, evidence-based decision making from all care providers, with decisions based on the care needs of individual mothers and babies.
The recently published Lancet Series on Midwifery indicates that the provision of skilled midwifery care is key to the safety of mothers and babies. This is equally true for the UK as for low income countries, and access to antenatal care must remain a priority. The recent confidential enquiries into maternal deaths in the UK found that more than two thirds of women who died did not receive the nationally recommended level of antenatal care.
There is strong research evidence for continuity of care in improving childbirth outcomes. Where a relationship exists between mothers and midwives before the birth, both are more able to recognise where health and or social problems occur.
One-to-one care by a midwife in labour has been a key target for maternity care for over 20 years. While politicians make promises about a midwife for every woman in labour, the public are entitled to ask why this is not already established in tablets of stone.
Since 60% of women who die in relation to childbirth do so following birth, high quality postnatal services must be provided to all women in the UK. The majority of UK women now leave hospital within one to two days following birth. At the same time community maternity services have been substantially reduced.
It is ironic that while more mothers with complex health problems are safely giving birth, routine postnatal midwifery support is being reduced. The death of one mother anywhere in the world is a tragedy, even more so when the majority of deaths may be avoided. The report from Save the Children shows that we have no room for complacency.