Rethinking maternal health
Authors: Felicia Marie Knaul, Ana Langer, Rifat Atun, Danielle Rodin, Julio Frenk, Ruth Bonita
Journal: The Lancet Global Health (2016)

Women's health has gone through a major epidemiological transition in the past decades. It is now time to rethink how global health defines maternal in order to encompass challenges to the health of all women, as well as their transformative potential as productive members of society.1Langer A Meleis A Knaul FM et al.Women and health: the key for sustainable development.Lancet. 2015; 386: 1165-1210Summary Full Text Full Text PDF PubMed Scopus (218) Google Scholar The term maternal refers, as generally defined, to life experiences that are not unique or restricted to pregnancy. Yet, the current global health use of maternal health concentrates attention to a narrow period of women's lives—pregnancy, childbirth, and 6 weeks' post partum. While this definition of maternal health shows tremendous inequities affecting women, it is restricted by its exclusive focus on the risks of bearing children. It does not consider the health of women who are not mothers, the many other problems that lead to premature death and disability, or the multiple roles women have in all societies. Furthermore, deaths associated with pregnancy, childbirth, and the postpartum period represent a decreasing fraction of women's overall burden of disease. The narrow focus on maternal health in relation to pregnancy and childbirth was appropriate historically. In low-income and middle-income countries (LMICs), the improvements in maternal deaths around childbirth were very modest during most of the 20th century, prompting a maternal and child health approach as a worldwide campaign to improve maternal health.1Langer A Meleis A Knaul FM et al.Women and health: the key for sustainable development.Lancet. 2015; 386: 1165-1210Summary Full Text Full Text PDF PubMed Scopus (218) Google Scholar, 2Rosenfield A Maine D Maternal mortality—a neglected tragedy: where is the M in MCH?.Lancet. 1985; 326: 83-85Abstract Scopus (327) Google Scholar These path-breaking initiatives successfully oriented work in global health for women—especially towards Millennium Development Goal 5. The most recent global estimates of the maternal mortality ratio show a decline from 385 per 100 000 live births in 1990 to 216 per 100 000 in 2015, with 303 000 maternal deaths in 2015.3Alkema L et al.Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group.Lancet. 2016; 387: 462-474Summary Full Text Full Text PDF PubMed Scopus (1096) Google Scholar While estimates vary across sources, all coincide with a significant decline.4Kassebaum NJ Bertozzi-Villa A Coggeshall MS et al.Global, regional, and national levels and causes of maternal mortality during 1990–2013: asystematic analysis for the Global Burden of Disease Study 2013.Lancet. 2014; 384: 980-1004Summary Full Text Full Text PDF PubMed Scopus (966) Google Scholar These major reductions are largely due to improvements in countries of low income, but most preventable maternal deaths continue to happen to the world's poorest women.1Langer A Meleis A Knaul FM et al.Women and health: the key for sustainable development.Lancet. 2015; 386: 1165-1210Summary Full Text Full Text PDF PubMed Scopus (218) Google Scholar Simultaneously, women worldwide have experienced a rapidly growing burden of chronic and non-communicable diseases (NCDs).5Bonita R Magnusson R Bovet P et al.Country actions to meet UN commitments on non-communicable diseases: a stepwise approach.Lancet. 2013; 381: 575-584Summary Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 6Norhei O Jha P Admasu K et al.Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health.Lancet. 2014; 385: 239-252Summary Full Text Full Text PDF Scopus (183) Google Scholar In 2013, among women aged 15–49 years, NCDs accounted for 44% of deaths and almost 65% of disability-adjusted life years compared with 7% of all deaths and 5% of all DALYs associated with maternal disorders. Cancers of the breast and cervix are now leading killers of this group of women in LMICs and deaths outnumber pregnancy-associated mortality in every developing region except in sub-Saharan Africa.7Knaul FM Bhadelia A Gralow J Arreola-Ornelas H Langer A Frenk J Meeting the emerging challenge of breast and cervical cancer in low and middle income countries. World Report on Women's Health, International Federation of Gynecology and Obstetrics.Int J Gynaecol Obstet. 2012; 119: S85-S88Summary Full Text Full Text PDF PubMed Scopus (34) Google Scholar In view of the remarkable transitions in the health needs and roles of women, a narrow conception of maternal health undervalues the burden of illness faced by women, because most women live past the age of child bearing. Narrow interpretations of maternal health adversely affect global health priorities, and can lead to a restrictive vision of the needs of women across their life cycle and restrict their potential to contribute to their families, communities, health systems, societies, and economies.1Langer A Meleis A Knaul FM et al.Women and health: the key for sustainable development.Lancet. 2015; 386: 1165-1210Summary Full Text Full Text PDF PubMed Scopus (218) Google Scholar, 8Bustreo F Chestnov O Knaul FM et al.At the crossroads: transforming health systems to address women's health across the life course.Bull World Health Organ. 2013; 91: 622Crossref Scopus (8) Google Scholar Premature deaths of women have profound effects on families, societies, and economies, regardless of the age at which they occur and whatever the cause, including an—often preventable—NCD or injury later in life. Families, especially if female-headed, are driven into poverty through catastrophic health expenditures and income loss, leaving them destitute.9Kadiyala S Quisumbing A Rogers B Webb P The impact of prime age mortality on child survival and growth in rural Ethiopia.World Dev. 2009; 37: 1116-1128Crossref Scopus (10) Google Scholar Children are often forced out of school and into the labour market or, in the case of girls, into home-bound caregiving.10Levison D Moe KS Knaul FM Marking time: an analysis of youth hours of work and study in urban Mexico.Rev Dev Econ. 2008; 12: 751-763Google Scholar, 11Case A Ardington C The impact of parental death on school outcomes: longitudinal evidence from South Africa.Demography. 2006; 43: 401-420Crossref PubMed Scopus (179) Google Scholar Ultimately, loss of an adult female also means the loss of a caregiver and nurturing figure. NCDs are now an internationally recognised health priority with a growing global movement.12UN General AssemblyPolitical declaration of the high-level meeting of the general assembly on the prevention and control of non-communicable diseases. A/66/L.1. Sept 16, 2011.http://www.un.org.ga.search.view_doc.asp?symbol=A/66/L.1Google Scholar Yet, little has been done to develop systemic responses to NCDs and women's health or to integrate these two global health agendas and approaches.5Bonita R Magnusson R Bovet P et al.Country actions to meet UN commitments on non-communicable diseases: a stepwise approach.Lancet. 2013; 381: 575-584Summary Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 13Atun R Jaffar S Nishtar S et al.Improving responsiveness of health systems to non-communicable diseases.Lancet. 2013; 381: 690-697Summary Full Text Full Text PDF PubMed Scopus (188) Google Scholar An integrated, comprehensive approach to maternal health across the life cycle, that makes use of existing health financing, infrastructure, cost-effective interventions, and programmes could help to address these gaps.13Atun R Jaffar S Nishtar S et al.Improving responsiveness of health systems to non-communicable diseases.Lancet. 2013; 381: 690-697Summary Full Text Full Text PDF PubMed Scopus (188) Google Scholar, 14Knaul FM Alleyne G Piot P et al.Health system strengthening and cancer: A diagonal response to the challenge of chronicity.in: Knaul F Gralow J Atun R Bhadelia A Closing the Cancer Divide: An Equity Imperative. Harvard University Press, Harvard2012: 93-114Google Scholar One example comes from Mexico, where a diagonal approach, merging a horizontal health system and vertical disease-specific initiatives, is being used to integrate awareness-building, early detection, treatment, survivorship care, and palliation for NCDs with population-wide, poverty-alleviation and primary care platforms.14Knaul FM Alleyne G Piot P et al.Health system strengthening and cancer: A diagonal response to the challenge of chronicity.in: Knaul F Gralow J Atun R Bhadelia A Closing the Cancer Divide: An Equity Imperative. Harvard University Press, Harvard2012: 93-114Google Scholar, 15Keating NL Kouri EM Arreola Ornelas H Mendez O Magana Valladares L Knaul FM Evaluation of breast cancer knowledge among health promoters in Mexico before and after focused training.Oncologist. 2014; 19: 1091-1099Crossref PubMed Scopus (19) Google Scholar The maternal and NCD agendas and movements can and should be synergistic. The Sustainable Development Goal for health (SDG 3), which includes maternal and child health as well as premature mortality from NCDs, presents an opportunity to implement an integrated approach for women of all ages. Indeed, the populations targeted by SDG 3 often overlap, as many women who live with or die from NCDs are mothers who survived childbirth. Estimates suggest that in 2030, a two-thirds reduction in maternal and child deaths and a third reduction in NCD mortality would mean 210 000 fewer maternal deaths and 690 000 fewer NCD deaths in women and girls aged 5–49 years, and 2·4 million fewer NCD deaths in women aged 50–69 years.6Norhei O Jha P Admasu K et al.Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health.Lancet. 2014; 385: 239-252Summary Full Text Full Text PDF Scopus (183) Google Scholar The global health community must rise to the challenge of competing risks rather than remain a victim of its own success. It is unacceptable and unethical to prevent a woman from dying in childbirth, yet to allow her to die of a preventable or treatable condition such as cervical cancer or diabetes. An either-or view of women's health is neither effective nor just. Global health must be inclusive and integrated with a focus on people rather than ailments, by replacing the disease-centred focus with a person-centred approach to priority setting. While retaining the focus on the equity imperative of the unfinished agenda of preventable mortality associated with pregnancy and childbirth, it is essential to address the expanding disease and injury burden that threatens girls and women throughout their life cycle as children, adolescents, mothers, grandmothers, and producers of health and economic, social, and human development.1Langer A Meleis A Knaul FM et al.Women and health: the key for sustainable development.Lancet. 2015; 386: 1165-1210Summary Full Text Full Text PDF PubMed Scopus (218) Google Scholar The maternal health agenda must encompass a life course, women-centred approach, including those who have children and those who do not. The challenge is to continue to push maternal health well beyond pregnancy and childbirth to enable all women to realise their full potential in all facets of their lives. It is time to rethink what is maternal about maternal health. We declare no competing interests.