Trend over time of maternal mortalityworldwide from 2000 to 2015In2000 the United Nations Millennium Declaration set out targets known as theMillennium Development Goals (MDGs) to improve the lives of the world’s poorestpeople (World Health Organisation (WHO) 2015a).Included in these goals was the aim to reduce the maternal mortality ratio (MMR,number of maternal deaths per 100,000 live births) globally by 75% from 1990 to2015 (United Nations (UN) 2015). Anambitious goal, considering the 12% reduction which occurred in the previousdecade from 1990 (WHO et al.

2015). The major causes of maternal mortality (MM) includehaemorrhage, sepsis, pre-eclampsia and unsafe abortions however lives could be savedif adequate contraception, abortion, ante; peri and post-natal care was available,particularly in the developing world (UN 2015).Considerable progress has been made, with global MMR reducing from 330 in 2000to 216 in 2015, an admiral reduction but less than the 75% target, perhapsreflecting an unrealistic goal from the outset (UN2015). The estimated annual decline in MMR did however accelerate from2000 to 2015 prompting optimism for the future (WHO etal. 2015).Whilethe global reduction of MMR is impressive it must be noted just 51% of countriesprovide, often incomplete, MM data (UN 2015).Disparities between and within countries are also masked by this data, with 26countries deemed to have made little or no progress reducing MMR and higherMMRs noted among marginalised groups, when such data is available (WHO  et al. 2015).

It must be consideredhow many maternal deaths are masked or not accounted for in the data? Challenges in reducing maternalmortalityThelack of accurate data on MM leads to difficulty determining the priorities totarget for improvement (UN 2015). It alsobegs the question, if governments are oblivious to the true levels of MM, howcan improvements be prompted, or the effectiveness of any interventions be measured?Whilecontraception, safe abortions and ante-, peri- and postnatal care can reducethe risk of MM the lack of accessibility and use of such services is achallenge to reducing MMR (Bullough et al. 2005; UN 2015). Ashighlighted by the UN, 64% of women globally who wish to avoid pregnancy are usingcontraception while just 28% of those in sub Saharan Africa are, only half ofwomen receive recommended antenatal care and 25% of babies are born withoutskilled personnel (2015). In remote areasthe distance and cost required to travel to and avail of healthcare precludeswomen attending (Kyei-Nimakoh et al. 2017).  In addition, numerous reports of mistreatment(Rominskiet al.

2017), fear of disease transmission (WHO  et al. 2015), HIV diagnosis (Byford-Richardsonet al. 2013), lack of equipment and staff training deter many fromattending for reproductive care (Kambala et al. 2011). In areas whereaccessibility to reproductive care is poor however caution must be exercisedbefore laying blame. The healthcare systems of many of these nations areoperating in fragile states under the burden of conflict and HIV epidemicswhich present further challenges (WHO  etal. 2015).

Theunique cultural and religious beliefs and practices throughout the world alsopresent a challenge to reducing MM (Evans 2013).Women in many areas do not have the power to make decisions regarding theirhealth (Lori and Boyle 2011) and so areless likely to seek advice regarding contraception, pregnancy and abortion (Osamor and Grady 2016). In Tibet pregnantwomen believe contact with strangers such as healthcare staff may negativelyimpact their health (Adams and White 2005),while in Mozambique public knowledge of pregnancy is feared to increasevulnerability to witchcraft (Chapman 2006).Many women opt to seek care from traditional birthing assistants instead of orin addition to medical care which they feel does not meet their spiritual and interpersonalneeds (Chapman 2006; Sarker et al. 2016). The unique cultural and religious beliefs ofdifferent ethnicities make it challenging to develop global models aimed atreducing MMR, but it is crucial they are respected and used to inform servicesto ensure success (Evans 2013). Innovations strategies that could beimplemented to reduce maternal mortalityTheWHO has identified many strategies to reduce MM including tackling inequalitiesin accessing care, ensuring universal health coverage, increasing the strengthof healthcare systems, focussing on all causes of MM and ensuringaccountability to improve the standard and equity of care (WHO  2015b).Asdiscussed, geography finance and gender inequalities may prevent access toservices aimed at optimising maternal health (Kyei-Nimakoh et al.

2017). Initiatives suchas maternity waiting homes (MWH), community outreach programmes and subsidieshave led to improvements in MM (United NationsChildren’s Fund (UNICEF) 2013). While it is crucial barriers don’tpreclude access to adequate care it is also imperative that once accessed thehealthcare provided is culturally acceptable (Evans2013). In Afghanistan for example while some MWHs are available manywomen were not admitted as their families prohibited them from staying (UNICEF 2013).

Ensuring adequate training ofstaff to provide quality, respectful care is also imperative to increase theacceptability of medical over traditional care (UNICEF2013). Investments in staff training in Cambodia for example led to anincreased proportion of births being attended by skilled personnel (UNICEF 2013). Further research in the form ofrandomised control trials are needed however to demonstrate which initiativeswork best to help guide the optimal use of resources. Whilethe WHO advocate tackling all causes of MM little focus appears to be directedtowards strategies to increase contraceptive use or safe abortion practices. Areview of both ‘Innovative Approaches to Maternal and New-born Health’ (UNICEF 2013) and ‘Strategies Toward EndingPreventable Maternal Mortality’ (WHO 2015b)yielded no specific guidance on tackling these issues. Further attention isneeded in these areas considering the significant effects they can have onreducing MM (Ahmed et al. 2012). Increaseddata collection including maternal death audits, verbal autopsies and near missreports have been instrumental in improving the quality, equity andaccountability of care and so MMR in areas such as India (Padmanaban etal.

2009; UNICEF 2013).  Improveddata collection alone is not enough however, to be effective results must beinterpreted, cause of death identified, and action taken to prevent further maternaldeaths (UNICEF 2013). With 49% of countrieshaving little information on MM the potential benefits of such strategies couldbe enormous. Whileadmiral reductions in MM have been achieved much still needs to be done.

Whilethis is an area of challenge it is also an area of opportunity to instigatechange.