Numerous aspects can send a woman down the road to maternal death. Lack of education leads to low levels of awareness about the prospective complications of childbirth and the importance of skilled birth attendants. Problems of logistics like transportation and social or cultural barriers might also result in women delaying or failing to seek proper treatment. Furthermore, in developing countries, where access to health-care services is limited, it is often the case that the majority of deaths occur in the community and not in a hospital or health centre.
Even with medical care, according to several studies, poor patient management, carelessness, indifference, and inappropriate or delayed action by health staff contributes to preventable maternal deaths. The neglect that women’s health and nourishment can suffer in contrast to men’s is evident when the body is taxed to its limits during pregnancy. Poor nutrition throughout a lifetime results in anaemia in half of all pregnancies worldwide. More than fourteen million adolescent girls give birth each year, many as a result of coerced sex or unwanted pregnancies. Their inexperienced bodies are more vulnerable and more unaccustomed with the pressures of pregnancy than the bodies of older women. In poorer countries, maternal mortality among girls under eighteen is between two and five times higher than among those over twenty. Poor women, especially those in rural areas, may lack access to medical assistance even when it is apparent that such assistance would be needed.
The problem of maternal mortality is often intertwined with the issues of fertility, contraception, abortion and the prevention of sexually transmitted diseases. The women’s control over their own reproductive lives can mean control over their own destinies. All over the world, women’s access to the means to control their own fertility is decidedly varied. A woman’s ability to plan how many children she wants and when she wants them is vital to the quality of her life, Moreover, in places where emergency obstetric care is not available, access to contraception may factually be a matter of a woman’s life or death. Each pregnancy increases a woman’s chance of dying from complications of pregnancy or childbirth. Women’s health is so much more than just a medical issue; it is cultural, political, economic, and most importantly, an issue of social justice.
II. Adolescence and motherhood
Adolescence is generally a time of good health for girls, with opportunities for growth and development. But it can also be a time of significant risk, particularly with regard to sexual activity and substance use. Around 90% of adolescents in the world live in developing countries, and approximately 600 million are female. Adolescence is a time of relatively low death and disease; it is a period of time when mortality rates are the lowest, but, it is also a time of huge physical, social and emotional changes. From the first indicators where a woman’s body experiences menstruation and the first cycles, it is here that complete sexual knowledge, awareness, education and health should be imparted to women and girls. However, in developing countries, it is the opposite where such topics and moot points remain to persist as a taboo and are left on the mercy of girls’ and boys’ discretion to figure it out, which could have deadly consequences with neither parties not aware of what happens should these changes create a problem in the health of women.
Girls’ experiences during this period and the opportunities and protection that their cultures and societies provide can make the difference in their lives between good health and the ability to contribute fully to society on the one hand, and suboptimal functioning marked by harmful behaviours that lead to ill-health and unhappiness on the other. Many adolescent girls face constraints and marginalization as a result of poverty, harmful social and cultural traditions, humanitarian crises and geographical isolation. These factors hinder their access to information, education, health care and economic opportunities.
For most girls early sexual activity is associated with coercion or even violence. The younger the woman is at first sex, the greater the likelihood that her sexual initiation is forced. Every year, an estimated 21 million girls aged 15–19 years in developing regions become pregnant, and approximately 12 million of them give birth. At least 777,000 births occur to adolescent girls younger than 15 years in developing countries. Around the world, however, adolescent pregnancies are more likely to occur in marginalized communities, commonly driven by poverty and lack of education and employment opportunities. Generally, adolescent pregnancy is more common in adolescents who live in poverty and in rural areas, and it is more likely to occur among the less educated. In developing countries, complications of pregnancy and childbirth are the leading cause of death in young women aged between 15 and 19 years. About 15% of total maternal deaths worldwide, and 26% in Africa, occur among adolescents.
The adverse health effects of adolescent childbearing are reflected in the poor health of their infants: perinatal deaths are 50% higher among babies born to mothers under 20 years of age than among those born to mothers aged 20–29 years. Moreover, babies of adolescent mothers are more likely to have low birth weight, which is a risk factor for ill-health during infancy. Early pregnancy and childbearing may be associated with significant health problems, including unsafe abortion. The health impact affects not only the adolescents but also their infants. In many societies, girls are under pressure to marry and bear children early. In the least developed countries, at least 39% of girls marry before they are 18 years of age and 12% before the age of 15. In many places, girls choose to become pregnant because they have limited educational and employment prospects. Often, in such societies, motherhood is valued, and marriage or union and childbearing may be the best of the limited options available.
Early pregnancies among adolescents have major health consequences for adolescent mothers and their babies. Pregnancy and childbirth complications are the leading cause of death among girls aged 15–19 years globally, with low- and middle-income countries accounting for 99% of global maternal deaths of women aged 15–49 years. In many cases, rapid repeat pregnancy is a concern for young mothers, as it presents further health risks for both the mother and the child. This also poses social and cultural risks to the young mothers as many girls who get pregnant early might from stigma, rejection or violence by partners, parents and peers. These girls are also more likely to drop out of school, and this affects their employment opportunities in the long run. Lack of government reforms and non-enforcement of laws regarding birth control is the final nail in the coffin for this social issue.
III. Maternal mortality
For most women, the years between puberty and menopause propose numerous opportunities for personal fulfilment and development. However, this can also be a time of many health risks specifically associated with sex and reproduction that may result in a momentous burden of mortality and disability. It has been found that in high-income countries, the three leading causes of female deaths are road traffic accidents, suicide and self-inflicted injuries, and breast cancer. Together, these account for more than one in every four deaths. On the contrary, the three leading causes of death in low-income countries are HIV/AIDS, maternal conditions and tuberculosis, which together account for one in every two deaths. The spread of HIV/AIDS is a gross product of unprotected sex – which is yet another factor evolving due to lack of sexual education and medical safety. Maternal mortality (i.e. the death of a woman during pregnancy, delivery or the postpartum period) is a key indicator of women’s health and status, and shows most poignantly the difference between rich and poor, both between countries and within them.
Maternal death which is also called maternal mortality is defined by the World Health Organisation (WHO) as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.” Majority of the maternal deaths occur during or very shortly after childbirth and most could be prevented if women were properly assisted at that time by a health-care professional with the necessary skills, equipment and medicines to prevent and manage complications. It has been found that poorer and less educated women and those living in rural areas are far less likely to give birth in the presence of a skilled medical health worker than better-educated women who live in wealthier households or urban areas. There are various reasons for this that include physical inaccessibility and prohibitive costs, but may also be the result of inappropriate sociocultural practices.
Nonfatal complications can also have life-altering effects on women. One example would be of obstetric fistulae, at least two million women worldwide suffer from obstetric fistulae, an opening between the vagina and the bladder or rectum that results from tissue damage during prolonged labour. Obstetric fistula is most common among young women, who have more difficult labour and more often lack access to proper care. In addition to pain, the fistula causes urine and/or faeces to pass through the vagina, which results in odour and infection. Women so afflicted are frequently deserted by their partners and exiled from their villages. A relatively simple surgical intervention can treat this problem, but access to appropriate facilities is beyond the reach of many women, particularly in rural areas. It has been estimated that from 1990 to 2015, the global maternal mortality ratio declined by 44 per cent – from 385 deaths to 216 deaths per 100,000 live births. Even though the maternal mortality rates have decreased, about 30 – 40 per cent of pregnant women, or around 54 million women in developing countries, are estimated to experience a pregnancy-related complication annually. Many more women suffer from associated illnesses that are aggravated by pregnancy—anaemia, malaria, cardiac disease, hepatitis, tuberculosis or diabetes. The WHO estimates that 12.5 million women each year are affected by these illnesses aggravated by their pregnancies. In the same report, it was also estimated that approximately 20 per cent of all maternal deaths in all regions are attributed to these indirect causes. Additionally, the nonfatal consequences of obstetric complications and associated diseases can severely affect women’s quality of life, fertility, productivity, and can result in chronic reproductive morbidities that may become evident only long after delivery.
Despite the ongoing challenges, there have been some reassuring trends. Since the 1990s, in countries with trend data, the presence of skilled attendants at delivery has increased in all regions, except East and Southern Africa, with a particularly marked increase in the Middle East/ North Africa. It is important to remember that most maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known. Antenatal care provides opportunities for regular check-ups to assess risks, as well as to screen and treat conditions that could affect both the mother and her baby. Maternal health and new born health are closely related. It is particularly vital that all births are attended by skilled health professionals, as timely management and treatment can make the difference between life and death for the mother as well as for the baby. Postpartum care is vital for detecting and treating infection and other conditions, including postpartum depression, and for providing advice on family planning.
In the context of the Sustainable Development Goals (SDG), countries have united behind a new target to accelerate the decline of maternal mortality by 2030. The SDG 3 includes a determined target: “reducing the global maternal mortality rates to less than 70 per 100,000 births, with no country having a maternal mortality rate of more than twice the global average”. Improving maternal health is also one of WHO’s key priorities. The World Health Organisation works to contribute to the reduction of maternal mortality rates by increasing research evidence, providing evidence-based clinical and programmatic guidance, setting global standards, and providing technical support to the Member States on developing and implementing effective policy and programmes.
IV. Female foeticide – a deadly preference
Sex selection in favour of boys is a symptom of prevalent social, cultural, political and economic injustices against women, and a manifest violation of women’s human rights. Such injustices must be addressed and resolved without exposing women and children to the risk of death or serious injury through denying them access to needed services and thus further violating their rights. Around the world, preference for sons is still alive. It ends up, resulting in discrimination and health risks for girls and women. In some regions, particularly in South and East Asia and many parts of Africa, being conceived a girl presents a major risk upfront—the possibility of not being born at all or not surviving infancy, of being one of the millions of girls who have disappeared from the demographer’s charts as a result of Foeticide, infanticide, neglect, and among the relatively wealthy, the sex-selective abortion. The famous economist Amartya Sen, the Nobel laureate in economics, estimated that the number of “missing” girls worldwide ranges from sixty to one hundred million, or about the same number of females born each year.
According to demographic projections, a population where everyone is treated equally in terms of access to food and health care ought to have at least as many females as males, and the sex ratio should be approximately 105 males to 100 females. However, in large parts of Asia, particularly in regions of China and India, the sex ratio among infants is unnaturally elevated to 115 or even 120 or more males for every 100 females, which indicates that at many places fewer young girls reach childhood than biology would predict. The economic and social pressures, both stemming from cultural inequalities in gender roles, induce parents to prevent the survival of female babies.
Son preference is manifest prenatally, through sex determination and sex-selective abortion, and postnatally through neglect and abandonment of female children, which leads to higher female mortality. Ever since prenatal sex determination became available in the mid-1980s, it has made a major contribution to imbalances in the sex ratio seen in many Asian countries. However, it is the combination of sex-selective technology and a small-family culture that has caused the highest sex ratios. Postnatally, the discrimination against daughters leads to neglect and disregard of their health care or nutrition, resulting in higher female mortality. This is especially the case in rural societies where health care costs have to be borne by the family.
Even though over the years, improved health care and conditions for women have resulted in reductions in female mortality, but these advances have now been offset by an enormous increase in the use of sex-selective abortion, which became available in the mid-1980s. Mostly, as a result of this practice, there are now an estimated 80 million missing females in India and China alone. The large cohorts of surplus males who are adults now are predominantly of low socioeconomic class and concerns have been expressed that their lack of marriageability, and consequent marginalization in society, may lead to antisocial behaviour and violence, threatening societal stability and security. Measures to reduce sex selection must include stringent enforcement of existing legislation, the ensuring of equal rights for women, and public awareness campaigns about the dangers of gender imbalance.
V. Sexually transmitted infections/diseases
There are more than 30 different bacteria, viruses and parasites that are known to be transmitted through sexual contact. Eight of these pathogens are linked to the greatest occurrence of sexually transmitted disease. Of these eight infections, four are currently curable: syphilis, gonorrhoea, Chlamydia and trichomoniasis. While the other four are viral infections which are incurable: hepatitis B, herpes simplex virus (HSV or herpes), HIV, and human papillomavirus (HPV). Symptoms or disease due to these fatal viral infections can be reduced or modified through proper treatment. But these diseases disproportionately affect women in developing countries who lack access to medical care. Many of these infections are asymptomatic or difficult to identify, particularly in women, but they have serious consequences, including infertility and death.
Globally, HIV is the leading cause of death and disease in women of reproductive age. Women’s particular vulnerability to HIV infection stems from a combination of biological factors and gender inequality. Some studies show that women are more likely than men to acquire HIV from an infected partner during unprotected heterosexual intercourse. Stigma and sexual violence by intimate partners further increase women’s vulnerability. Fewer young women than young men know that condoms can protect against HIV.
Delays in diagnosis and treatment, coupled with women’s greater biological vulnerability to complications from the untreated infection, result in women suffering far more considerable morbidity due to sexually transmitted infections than men do. The treatable infections such as gonorrhoea, Chlamydia, syphilis and trichomoniasis, not only give rise to acute symptoms but also provoke a chronic infection. The longer-term consequences of sexually transmitted infections include infertility, ectopic pregnancy and cancers, as well as increased vulnerability to HIV infection. Sexually transmitted infections increase the risk of adverse pregnancy outcomes, including stillbirths, low-birth-weight infants, neonatal deaths and congenital syphilis. In addition, women bear much of the stigma associated with these infections.
Another sexually transmitted infection, the human papillomavirus (HPV), is important to women’s health principally because of its relationship to cervical cancer and other genital cancers. Infection with HPV is widespread, and 10% of women with normal cervical cytology at any point in time are positive for HPV in the cervix. HPV is more prevalent in less developed countries where it stands at 13% overall, while in the more developed regions, it is estimated to be at 8%. Cervical cancer is globally the second most common type of cancer among women, and virtually all cases are linked to genital infection with HPV. In 2018, an estimated 570,000 women were diagnosed with cervical cancer worldwide, and about 311,000 women died from the disease. A highly effective vaccine against HPV is now available, but cost and accessibility limit its use in less developed countries. Cervical cancer can also be prevented through regular screening coupled with treatment, but this is rarely available in most developing countries.
VI. Women’s access to contraception
Unintended pregnancy, resulting from an unmet need for contraception, threatens the lives and wellbeing of women and their families globally. The latest estimates are that 222 million women have an unmet need for modern contraception, and the need is greatest where the risks of maternal mortality are highest. In the least developed countries, about 6 out of 10 women who do not want to get pregnant, or who want to delay their pregnancy, are not using any method of contraception. Unequal access to contraception and ineffective use of available methods has meant that almost half of the 200 million pregnancies that occur each year “are unwanted or ill-timed.” More than a quarter of pregnancies worldwide (about 42 million annually) end in abortion, split about equally between legal and illegal abortions. Of the approximately 125 million births each year, more than one quarter are unwanted—16% are not wanted at the time, and 11% are not wanted at all. The women’s lack of knowledge about and the access to contraceptives has colossal consequences in terms of the situation of individual families as well as the demographics of societies and the prosperity or poverty of their immediate society.
Different patterns of contraceptive use might not reflect women’s personal preferences as much as political and economic decisions made by governments to promote certain methods, the attitudes of medical experts, comparative costs, the restricted range of methods offered in some countries, or an irregular availability of contraceptive supplies. In fact, high-quality family planning services are very often not available, as the UN Population Fund notes: “One evaluation of family planning programs in eighty-eight developing countries concludes that family planning services are routinely made available to women at a reasonable cost in only fourteen countries. In many developing countries, at least a third of women need contraceptive services: Some women, like many of the young women in Jamaica, do not know about modern methods, are unable to obtain or afford them, or distrust or dislike the methods that are available. Single women and teenagers may be barred from obtaining contraceptive services. Many women are ambivalent about whether they want a child or are unsure about their ability to become pregnant. Still, others live with a partner who does not approve of contraception or who wants them to become pregnant.”
The most commonly used type of contraception in developing countries is female sterilization, which 22% of married women have undergone, more than male sterilization (3%), condom use (4%), and the pill (7%) combined. While in the developed world where more flexible options are available, sterilization is only half as prevalent. Between 30 and 40 per cent of pregnant women, or over 54 million women in developing countries, are estimated to experience a pregnancy-related complication annually.
Contraception has clear health benefits since the prevention of unintended pregnancies results in a subsequent decrease in maternal and infant mortality and morbidity. In addition to a reduction in maternal and infant morbidity and mortality, access to and use of contraception also contributes to individuals being able to take control over their sexuality, health and reproduction, thus helping them to achieve a satisfying sexual life. The provision of contraceptive information and services that respect individual privacy, confidentiality and informed choice, along with a wide range of safe contraceptive methods, increase people’s satisfaction and continued use of contraception. Evidence also shows that health policies and programmes have a more positive effect on health outcomes when affected populations take part in their development. The legal environment has an important role to play and contributes to sexual health when it is in line with human rights standards.
VII. Safe and legal Abortion
According to WHO, providing women across the globe with access to safe and legal abortion services is essential to realizing and protecting their fundamental human rights. Unsafe abortion is one of the four leading causes of maternal mortality and morbidity. One of the reasons for unsafe abortion is because safe abortion services are frequently not available, even when they are legal for a variety of indications in almost all countries. Unsafe abortion accounts for 13% of maternal deaths. Nearly all deaths and morbidity from unsafe abortion occur in countries where abortion is severely restricted in law and in practice. Every year, about 47,000 women die from complications of unsafe abortion, an estimated 5 million women suffer temporary or permanent disability, including infertility. Where there are few restrictions on access to safe abortion, deaths and illness are dramatically reduced.
The 1994 UN Conference on Population and Development, held in Cairo, recognized the magnitude of this issue and acted to improve care for all women suffering from the effects of unsafe abortions, though it stopped short of recommending legalizing abortion more broadly. As of 2010–2014, an estimated 55.9 million abortions occur each year—49.3 million in developing regions and 6.6 million in developed regions.
Around 25 million unsafe abortions were estimated to have taken place worldwide each year, almost all in developing countries. Of these, one third or approximately 8 million were performed under the least safe conditions by untrained persons using dangerous and invasive methods. Unsafe abortions lead to an estimated 7 million complications. Among these, 8 million were carried out in the least- safe or dangerous conditions. Over half of all estimated unsafe abortions globally were in Asia. 3 out of 4 abortions that occurred in Africa and Latin America were unsafe.
Unsafe abortions occur overwhelmingly in developing regions, where countries that highly restrict abortion are concentrated. But even where abortion is broadly legal, inadequate provision of affordable services can limit access to safe services. In addition, persistent stigma can affect the willingness of providers to offer abortions and can lead women to prioritize secrecy over safety. In addition to the deaths and disabilities caused by unsafe abortion, there are high social and financial costs to women, families, communities, and health systems. In 2006, it was estimated that US$ 553 million was spent treating the severe consequences of unsafe abortion.
Evidence increasingly shows that, where abortion is legal on broad socioeconomic grounds and on a woman’s request, and where safe services are accessible, both unsafe abortion and abortion-related mortality and morbidity are reduced. Nearly a third of UN Member States allow abortion upon the free and informed request of the pregnant woman. An enabling environment is needed to ensure that every woman who is legally eligible has ready access to safe abortion care. Policies should be geared to respecting, protecting and fulfilling the human rights of women, to achieving positive health outcomes for women, to providing good-quality contraceptive information and services, and to meeting the particular needs of groups such as poor women, adolescents, rape survivors and women living with HIV.
This paper attempted to showcase the global perspective and trends related to women’s maternity and reproductive health. The heath of girls and women have improved much over the past sixty years. But the gains have been unevenly spread. While the developed countries have significantly improved their position with regards to the reproductive health of women, developing and underdeveloped countries still lag in this aspect. Thousands of women die each year due to a preventable health hazard, who could have been saved if they had been assisted or helped by skilled medical professionals and had the proper medicine been given to them at a crucial time. Now, women across the world are addressing these difficult and complicated issues that affect their own lives and society. More women are coming forward with their stories with the help of civil societies and women groups; this had led to better data collection and more research on the field, which will further lead to better outcomes.
The main priorities for the future should include: increased number of births attended by skilled birth attendants in all countries especially the ones with high maternal mortality rates; making sure that a continuum of antenatal, delivery and postpartum care is available and accessible to all pregnant women; ensuring that all women have access to modern contraception along with safe and legal abortion services that include post-abortion care and screening. The treatment for sexually transmitted infections, including HIV and HPV, should also be widely available to all. For the overall protection of women, it is crucial to increase awareness and prevent any intimate partner violence and sexual violence. It is also vital to ensure that women have access to essential reproductive health care and services during humanitarian crises. Improving women’s health will lead to an improvement in the society.
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