The 17 September marks World Patient Safety Day, and this year the focus is on ‘Safe maternal and newborn care’. Patient Safety Learning has recently published a blog highlighting and summarising this topic. While issues of unsafe care are a global challenge, they disproportionately impact on low- and middle-income countries. 134 million adverse events occur in hospitals every year in such countries, contributing to 2.6 million deaths. Research in patient safety has primarily been associated with high income countries, but more recently there has been greater attention on low- and middle-income countries due to the global awareness of the need to improve patient safety standards for all patients, including maternal care.
Worldwide, around 295,000 women died during and following pregnancy and childbirth in 2017. Approximately 810 women and 6,700 newborns die every day from preventable causes related to pregnancy and childbirth. These global statistics are shocking and highlight the attention that is needed to address maternal safety.
Of all the global maternal deaths, 94% occur in low- and middle-income countries. This reflects inequalities in access to quality health services and highlights the global gap between rich and poor. Of the many health statistics monitored by the World Health Organization (WHO), the largest gap between rich and poor nations is seen in maternal mortality levels. Sub-Saharan Africa and Southern Asia accounted for approximately 86% of the estimated global maternal deaths in 2017. Adolescent girls are more likely than older women to die due to complications related to pregnancy and childbirth; this is the leading cause of death for adolescent girls in low- and middle-income countries. Infants also suffer greatly – of the approximate 8 million infant deaths each year, around two-thirds occur in the first month of life in low income countries. Moreover, about 2 million babies are stillborn every year, with over 40% occurring during labour.
Maternal deaths occur as a result of complications that can transpire during and following pregnancy and childbirth, most of which are preventable or treatable. The major complications that account for nearly 75% of all maternal deaths include severe bleeding after childbirth, infections and pre-eclampsia. Additionally, for every woman who dies, at least 30 others are injured, often in disabling and socially devastating ways. For example, obstetrical fistula is common in poor communities in sub-Saharan Africa and South Asia, where access to maternal health services is limited. Most of neonatal and perinatal deaths are the result of poor maternal health and inadequate care during pregnancy and delivery and the critical immediate postpartum period.
The main factors that prevent women from receiving or seeking care during pregnancy and childbirth in low- and middle-income countries are poverty, distance to facilities, lack of information, inadequate and poor-quality services, and cultural beliefs/practices. For instance, 35% of Senegalese women who live in rural areas deliver their children at home, often without a skilled midwife or birth attendant present, which poses dangers to both mother and child. Care by trained staff is vital in preventing maternal deaths in low-income countries, yet only about half of births in such countries occur in health facilities. Poor person-centred maternity care (PCMC) is one of the main factors driving both the low proportions of facility-based deliveries and high maternal mortality. There is also a strong connection between the low societal status of women in low income countries and the risk of maternal illness and death.
The reality is that most maternal deaths are preventable, as the healthcare solutions to prevent or manage complications before, during and after childbirth are well recognised. It is particularly important that all births are attended by skilled health professionals because timely management and correct treatment can preserve the life of both mother and baby. To improve maternal health in low- and middle-income countries, barriers that limit access to quality maternal health services must be identified and addressed at both health system and societal levels. While additional resources are essential to patient safety improvement in low-income settings, such resources on their own will not be enough to secure the changes needed.
Recognising the scale of this problem, improving maternal health is now one of WHO’s key priorities. Whilst many other health indicators have improved over the last two decades, maternal mortality rates in low- and middle-income countries have remained high and progress in reducing maternal and newborn mortality has been very slow. Unsafe maternal care represents a serious and considerable danger to patients in low income countries – primarily due to scarce resources, weak infrastructure, cultural beliefs and limited skilled professionals – hence it should be a high priority public health problem that needs drastic attention.
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