Professor Bo Jacobsson on preventing Maternal and Neonatal Mortality
Professor Bo Jacobsson, FIGO Division Director of Maternal and Neonatal Health 2021-2025, was the Maternal and Newborn Health Theme Leader of the FIGO World Congress Scientific Programme Committee. He discusses strategies to reduce maternal and neonatal mortality worldwide, and the importance of tackling preterm birth.
How can we prevent maternal deaths and save women’s lives?
To avoid maternal death, it's vital to prevent unintended pregnancy. All women, including adolescents, need access to contraception, safe abortion services and high-quality, post-abortion care. Pregnancy should be intended and planned, and women should have their reproductive rights protected in different ways. This is key to reduce maternal death.
Most maternal deaths are preventable as healthcare solutions to prevent or manage complications are well known. All women need access to high-quality care during pregnancy, as well as during and after childbirth. Maternal health and newborn health are closely intertwined. It's important that all births are attended by skilled health professionals as timely management and treatment can make a difference between life and death for women, as well as for their newborns.
What can be done to address the most common causes of maternal deaths?
The most common cause of death during pregnancy is postpartum haemorrhage. It can kill a healthy woman within hours if not treated appropriately, but injecting oxytocins immediately after birth effectively reduces the risk of bleeding. FIGO has a clear strategy recommending a bundle approach, including uterotonics, to prevent and treat postpartum haemorrhage. The recent eMOTIVE study of 80 hospitals and over 200,000 women in Africa revealed that early detection of PPH with a bundle treatment approach led to reduced PPH and death. These results relied on measuring blood loss and rapid first-response treatments with uterine massage, oxytonic drugs, tranexamic acid, intravenous fluids, examination and escalation. FIGO believes that there is no question that uterotonics are essential but insists that they need to be an integral part of a systematic bundle approach.
Infection and sepsis are after childbirth are also a great risk, but they can be eliminated if good hygiene is practised. Recognising and treating the early signs of the infection in a timely manner can also prevent maternal death. Preeclampsia should be detected and appropriately managed before the onset of convulsions, eclampsia, and other life-threatening complications that can occur due to pre-eclampsia. Administrating drugs such as magnesium sulfate during preeclampsia can lower the maternal risk of developing eclampsia. FIGO has a clear strategy and is also running a leadership initiative to promote, for example, magnesium sulfate with this purpose.
Why are women not getting the care that they need?
Poor women in remote areas are the least likely to receive adequate health care. This is especially true for regions with relatively low numbers of skilled healthcare providers, such as sub-Saharan Africa and Southern Asia. The latest available data suggests that in most high-income and upper-middle-income countries, approximately 99% of all births benefit from the presence of trained midwives, doctors, and nurses, however, only 68% in low-income and 78% in low-middle-income countries are assisted by such skilled health professionals.
Key factors that prevent women from receiving or seeking care during pregnancy and childbirth are health system failures that translate to poor quality of care, including disrespect; mistreatment; and abuse; inadequately trained health workers; shortages of essential medical supplies and poor accountability of the health system. Another set of obstacles is the social determinants, including income, access to education, race, and ethnicity, which put some sub-populations at greater risk. Another is harmful gender norms and inequalities that result in a low prioritisation of the risk of women and girls, including the rights to safe, quality, affordable sex or reproductive health services. Also, external factors contribute to instability of the health system, such as climate and humanitarian crises.
To improve maternal health, barriers that limit access to high-quality maternal health services must be identified and addressed at both health system and societal levels.
What is the association between Caesarean sections and maternal health?
Another thing that is very important to bring up when discussing maternal health here is the pandemic of Caesarean section. In some countries, the Caesarean section rate is around 80%. There are many reasons behind this, but whatever reasons there are, the Caesarean section comes with increased risk both for the current pregnancy and delivery, and also long-term. So it's important that we focus on promoting normal vaginal birth by providing a Caesarean section only when it's needed. In some parts of the world, there are women who do not have access to Caesarean sections when needed, but in many other parts of the world too many Caesarean sections are provided, and long-term effect of Caesarean section can be serious like placenta accreta, and other life-threatening conditions.
Improving maternal health is one of FIGO’s key priority. FIGO 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 societies on developing and implementing effective policies and programmes. FIGO is working with partners like the WHO in supporting countries and member societies 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; 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.
How can we prevent neonatal deaths?
The key question is how we prevent neonatal deaths in relation to preterm birth. The Born Too Soon report, launched in May 2023 in Cape Town, documents what we can do to reduce preterm delivery. The rate of preterm delivery in the world has over the last decade been a flat line and even increased in some parts of the world. There are two major intervention strategies and we do need to start primary prevention of preterm birth.
The prevention of preterm birth is about preconception care, including family planning. It's important that women can choose when they want to be pregnant, because that is one of the basic principles to have a safe and successful pregnancy. Another key aspect is to have access to high-quality care that is supported by scientific evidence. The third point is childbirth care, including reducing initiated birth unless it is medically necessary. In addition to this, one of the new things the Born Too Soon report brings up is the need to focus on intersectoral interventions such as nutrition, girls' education or mitigation of climate change. Intersectoral interventions may be the most effective way of reducing preterm delivery.
And how can we improve neonatal care?
It is very important that obstetricians, together with midwives and neonatologists, work together to provide high-quality, family-centred, respectful care for every newborns. This includes essential newborn care, especially neonatal resuscitation and feeding support. The WHO, together with FIGO and others, has launched a report on “kangaroo mother care”, noting the importance of caring for the baby skin-to-skin from the earliest possible moment.
We should also focus on improving preterm care of the babies, especially with respiratory distress, infections, and jaundice if they are born too soon, and neonatal intensive care. There needs to an extension of the offer of neonatal intensive care in the world to increase the survival of the preterm infants. For paediatricians and midwives, it's important that women with threatening preterm delivery can be offered antenatal steroids wherever they are in the world because antenatal corticosteroid decreases mortality and long-term morbidity.
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