Maternal Mortality - Underlying Causes, Policy Implications, And Organizational Interests

Underlying root causes

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According to the World Health Organization (WHO), “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 cases” (Who.int 2018). Maternal mortality is a significant concern in the modern World. The maternal mortality rates have dropped from 385 deaths to 216 deaths per 100,000 live births from 1990-2015, which is a decline of 44% of the global ratio of maternal mortality. However, this is only 5.5% of the annual rate, which is needed to achieve the maternal mortality reduction target. Maternal mortality is a significant concern, particularly in the regions of Africa. Maternal mortality rates are unacceptable in the sub-Saharan regions of Africa (World Health Organization 2015). Moreover, compared to the countries of high socio-economic status, the countries with poor socio-economic status are far more affected with respect to maternal mortality. This is because the developed countries have a maternal mortality rate of 1 in 3300, while for developing countries, it is 1 in 41. The maternal mortality ratio in the developing countries is 14 times higher than the maternal mortality ratios of the developed and high-income countries (World Health Organization and Unicef 2014). The percentage of women requiring or undergoing antenatal care has also increased from 65%, which was observed in the year 1990 to 83% in the year 2012. This is particularly high among the developing countries. Moreover, not all women receive the necessary amount of healthcare services required, particularly in the developing countries (Tran Khanh 2012). Although maternal mortality rates has decreased but more than 800 women die each day due to complications resulting from pregnancy and child birth (Haddou 2018). Both Sub Saharan Africa and South Asia contribute to significant numbers of the maternal deaths observed worldwide (Blencowe et al. 2012). Proper family planning and sanitation are some of the interventions that can help to reduce the maternal deaths. This policy brief concentrates on the maternal mortality rates on Africa as compared to other countries and identifies the root causes of the problem. The policy brief is directed towards the Government and the participants in the culmination and application of the policy will be the healthcare organizations, non-government bodies, among others.

Policy implications of maternal mortality

Approximately, 289,000 women die every year due to childbirth complications resulting from sanitation. Lack of family planning, results in early pregnancies, unintended pregnancies and abortions that contribute to maternal deaths (Usaid.gov 2018). Teenage pregnancies and lack of use of contraceptives also results in maternal deaths. Another case of concern is the HIV infections, which account for 40% of maternal deaths. These are some of the preventable causes of maternal mortality. Other preventable causes of maternal mortality are haemorrhage, which accounts for 27% of deaths, presence of pre-existing medical conditions that are aggravated due to pregnancy, pregnancy hypertensive disorders like eclampsia, sepsis, embolism, unsafe abortion practices also contribute to the preventable causes of maternal deaths worldwide, particularly in developing countries (Filippi et al 2016). Lack of skilled healthcare personnels, supplies and equipments prevent timely care of women going through various pregnancy or child birth related complications. Lack of equipments and skilled doctors and nurses, particularly in the developing countries also results in improper diagnosis of the complications, thereby preventing timely treatments and in turn contributing to increased maternal mortality rates. Presence of complications results in timely interventions like the use of services like administration of life saving drugs, blood transfusions, surgical interventions like caesarean sections, among others (Nnebue et al. 2014).

The consequences associated with maternal mortality has far reaching effects. Studies have revealed that increase in maternal mortality results in increased rates of mortally among the children. It also results in decreased nutrition and proper education of children. Maternal deaths are also associated with social and economic crisis, particularly in the developing countries. In the developing countries like Africa, mothers are also earners of the family and maternal deaths results in financial instability, difficult management of the household, loss of education, among others. These are some of the long term consequences associated with maternal mortality (Molla et al. 2015). Some of the policies particularly in the developing countries that have been implied to reduce maternal mortality are fee exemption policy. According to this policy, delivery fees during child birth will be reduced in regions of Ghana. Along with this a method called the “Rapid Ascertainment Process for institutional deaths” were also applied. It revealed that after application of the policy, maternal death rates were significantly reduced (Johnson, Frempong-Ainguah and Padmadas 2015). Some of the other policy implications are evaluation of safe pregnancy and motherhood programs, use of skilled health workers specialized in emergency obstetrics in order to reduce maternal deaths in rural areas, improvement of health facilities, helping the poor socio-economic groups get safe care delivery services in order to prevent deaths caused by pregnancy related complications, monitoring of maternal care services, se of context specific indicators to evaluate and monitor maternal health, evaluation of economic aspects of healthcare systems with the use of specific tools and enhancement of research works for further evaluation of the intervention and monitoring programs (Gov.uk 2018).

Organizational interests

The World Health Organization is particularly, interested in this problem of maternal mortality that is gripping the population of sub Saharan Africa. Maternal mortality in sub Saharan Africa is associated with various causes like anemia, diabetes or hypertension, mental health conditions like depression, among others. Other factors include obstructed labour, obstetric fistula are also associated with high rates of morbidity and mortality (Filippi et al. 2016). The World Health Organization along with others partners are involved in the development of tools and other measures to overcome these shortcomings. The World Health Organization also defines the roles played by unsafe abortions in contributing to maternal deaths. According to the World Health Organization, unsafe abortion is “the termination of an unwanted pregnancy, either by persons lacking the necessary skills or in an environment lacking minimal medical standards or both”. Although the maternal mortality ratios have been reduced throughout the World, the most significant reduction observed in Eastern Asia of about 72%, Sub Saharan Africa shows only a very poor decline of only 45% in comparison to others countries (Who.int 2018). The World Health Organization has given rise to a number of statistical data that have shown that 73% of maternal deaths are due to obstetric causes and 27.5% are due to indirect causes. Hemorrhage constituted 27.1% of maternal deaths, hypertension constituted 14%, sepsis was 10.7%, unsafe abortions were 7.9% and embolism contributed to 12.8% of maternal deaths in Sub Saharan Africa. Indirect causes contributed 70% to maternal deaths. Indirect causes as observed by the World Health Organization, were found to be HIV/AIDS, preexisting conditions associated with diabetes, hypertension, depression, among others (Storm et al. 2014; Black et al. 2016). The World Health Organization’s millennium development goal 5 was to improve maternal health and therefore to reduce maternal mortality rates (Who.int 2018). However, such health strategies of the millennium development goals with respect to maternal mortality has be used to create an agenda or a sustainable development goal that can have global implications involving not only the health of women but also ensure the well being and health of all individuals belonging to different age groups (Sustainabledevelopment.un.org 2018).

Family planning policies as part of the millennium development goals to reduce maternal mortality is one of the policy options as described by the World Health Organization (Kyei-Nimakoh, Carolan-Olah and McCann 2016). This policy provides evidences with respect to multiple benefits associated with family planning. It shows the importance of family planning in maintenance of health and also for the socio-economic development of the country’s population. The policy therefore supports the cause of family planning in order to curb the health priorities affecting the current World Population. According to this policy the main benefits associated with family planning are associated with maternal mortality rates and health. Contraception reduces the number and also alters the timing of the pregnancies, which in turn has an impact on the health of the mothers as well as on the children. By increasing the contraceptive se to 10%, the rate of births and fertility are reduced, thereby resulting in a positive impact on the health of the women. Fertility regulation plays an important role in reducing the rate of maternal deaths (Adedini et al. 2015). Fertility decline played an important role, particularly in the developing countries to reduce the maternal mortality rates by 1.2 million in 2005 and by 1.7 million in 2008. The policy indicates that maternal deaths can be reduced by 30% if the women use contraceptives in order to avoid future pregnancies. The policy identifies two possible mechanisms by which contraceptives can reduce maternal mortality ratios. These include pregnancy aversions which would result in lowering the risk to the mother aged between 18-34 years and also reduces the rate of unsafe abortions. Another mechanism that was identified was that use of contraceptives results in improvements in obstetric health provisions. Moreover, other benefits that were identified involved survival and health of newborns (Familyplanning.org.nz 2018). The social benefits identified by the policy was that family planning or contraception resulted in women’s education and empowerment. Greater empowerment was found to be associated with greater use of contraceptives and in turn resulted in decreased maternal mortality rates and decrease in unwanted pregnancies. A low fertility setting for women results in increase in women employment and participation in public activities, which in turn ensures brighter future. The policy also identified the economic impacts associated with family planning and indicated that such family planning interventions, particularly in the developing countries helped to reduce the health delivery service costs with respect to disability adjusted life years, maternal and child deaths. African countries, where the population is growing at a rapid rate, the World Bank indicates that such a rapid population growths results in large number of savings deficits. Moreover, the environmental benefits were also outlined by the policy, which indicated that population growths resulted in large consumptions of the environmental resources and also increased carbon-dioxide emissions, mainly in the least developed countries. The policy implications were identified to be positive impacts on the health of women as well as children, apart from socio-economic developments. Contraceptions help to reduce the rate of child births and also help to space the child births, thereby resulting in women empowerment as well as reductions in maternal mortality (Apps.who.int 2018).

However, even though family planning helps to prevent and thereby reduce the rates of maternal and child mortality, women in many developing countries like South Africa still do not use contraceptives and as a result the number of unintended pregnancies, abortions and maternal deaths are high. Lack of proper scaling up strategies for promoting the use of contraceptives results in low usage. Other than lack of scaling up strategies, absence of maternal care facilities also results in increased maternal deaths in South Africa (Chola et al. 2015). Necessary recommendations include reduction in the costs of the contraceptives and also family planning educational programs in order to educate more women and also their families particularly in the rural areas to use contraceptives and control unwanted or untimely fatal pregnancies. Other shortcomings of the family planning policies or the reasons why the policy is failing is that beliefs of patients and providers play an important role in influencing the use of contraceptives. Misconceptions present in various regions of Africa such as Uganda, with respect to the use of contraceptives also deter them from following the family planning guidelines. According to them contraceptives can damage the uterus and also can result in death. Moreover, other barriers included discussions about contraceptives to be unacceptable, provider beliefs like contraceptives can induce female infertility, unwillingness to distribute contraceptives to unmarried individuals, among others. Other barriers are limited availability of contraceptives, lack of qualified and skilled healthcare personnels, misconceptions of health risks, lack of consent from male partners and limited access to contraceptives also prevent the use of contraceptives and adhere to family planning guidelines (Uniteforsight.org 2018; Ackerson and Zielinski 2017; Celik 2016).

Another policy as defined by the Sanitation and Hygiene Applied Research for Equity (SHARE) implicates lack of sanitation and hygiene as well as poor access of water negatively impacts both maternal and child health (Who.int 2018; Waterinstitute.unc.edu 2018). According to this policy there is a strong correlation between maternal mortality and lack of sanitation, hygiene and water. The lack of hand hygiene has also been associated with increased maternal and child deaths. The causes described in this policy with respect to maternal deaths were poor sanitation and unsafe management of water. Evidences revealed that poor sanitation resulted in hookworm infections, which can cause anaemia and increase the risks associated with maternal deaths. Hookworm infections were also found to cause Listeria, which were associated with pre-term births and spontaneous abortions. Poor sanitation related Schistosomiasis is also associated with anemia, ectopic pregnancy and under nutrition among pregnant women. This in turn results in poor health outcomes for the pregnant women (Campbell et al. 2015). Moreover, infections caused by poor sanitation results in obstructed labour and increased risk of maternal mortality (Filippi et al. 2016). Poor sanitation also increases the risk of pre-eclampsia, urinary tract infections, thereby resulting in negative health outcomes for women. Moreover, unsafe water can increase risks of infections associated with fecal oral routes and can also result in increased infections like malaria and dengue, which poses a serious threat to pregnant women (Minassian et al. 2013). Moreover, contamination of water by arsenic and fluorides results in still births and higher rates of spontaneous abortion. SHARE has helped to carry out research in the field of sanitation and maternal health. The policy identified a conceptual framework named the Bradley classification, which identified the risk factors associated with maternal health outcomes. This classification helped to identify the risk factors and classified them into biological, chemical and behavioral mechanisms. Other studies identified in this policy brief showed that poor water sanitation is associated with increased maternal mortality rates and also indicated that poor access to safe water also contributed to increased risks of maternal mortality. Moreover, assessments carried out revealed that in Tanzania, less than one third of births take place in safe water and sanitation regions (Benova et al. 2014). Needs assessments were also carried out, which showed that poor functioning of water system, contaminated hospital beds, lack of hand washing stations had been found to be responsible for the high maternal mortality rates in Zanzibar and India (Assets.publishing.service.gov.uk 2018; Steinmann et al. 2015). The needs assessment study also revealed that poor sanitation and open defecation is associated with adverse pregnancy outcomes. The policy revealed that additional work is required to enhance the evidence base and identify the various sanitation interventions that can have a positive impact on maternal health, thereby enabling to reduce the maternal mortality rates. The policy contributed to research with respect to identifying the risk factors and in this respect helped to identify that sanitation problems and lack of access to safe water are some of the determinants of maternal health. The policy also provides recommendations that indicates the requirement of support from donors, governments and agencies. It also recommends the requirement of infrastructures, monitoring, training and supplies in order to ensure the hygiene particularly in delivery and operating rooms. Moreover, it also recommends the implementation of the WASH policy in the post 2015 development framework and also ensures that financial resourcing be carried out in order to embed WASH in core health strategies (Lshtm.ac.uk 2018).

However, the WASH policy has some barriers, which prevents its success. These include lack on information, differences in mindsets, lack of coordination, lack of political and financial support, lack of demand, donor agendas, lack of service providers, lack of human and technical resources, limited access, lack of promotion, lack of cleaning arrangements, cultural factors, among others. Lack of proper information about the existing conditions of sanitation, lack of clarity with respect to institutional responsibilities in developing countries, lack of budgetary allocations, lack of skilled and disciplined workers can also result in preventing the implementations of the WASH policy. Moreover, in countries like Africa, lack of hygiene providers like local governments, NGOs, community associations and private suppliers also prevents the implementation of the WASH policy. Additionally, lack of promotional strategies also have no impact particularly in the rural population and promotional strategies are required to create links between sanitation and maternal mortality, which in turn can have an impact on the rural populations of developing countries. Developing countries also do not have community sanitation facilities, which also prevents the reduction of maternal mortality rates. Cultural factors also are potential barriers to policy implementations, which include variations of the perspectives of individuals with respect to sanitation facilities. Moreover, varying beliefs of different ethnic groups also pose a problem to policy implementations (Waterfund.go.ke 2018; Sahoo et al. 2015).

However, keeping in mind the shortcomings of the policies described in the above sections, certain recommendations that can be beneficial in further inducing the implementations of the policies include access to skilled care to women in developing countries before, after and during child births, training of health providers with emergency obstetrics care, increasing the supplies in healthcare centers, education of communities in order to strengthen the maternal healthcare organizations, skilled technicians who can assist in child birth and manage complications in rural areas, increase in funding from Government and non-government organizations, among others (Ncbi.nlm.nih.gov 2018). Other recommendations involve promotion of sanitation and family planning strategies on a large scale, particularly in rural areas and also monitor the services provided by the healthcare centers. Moreover, misconceptions can be removed by utilizing members from local communities in promotional programs in order to obtain the trust of the individuals with respect to the health promotion programs. Women supervisors should be included in the promotional programs so that the women in developing countries and various rural areas can talk about their problems, which is otherwise not possible in the presence of male counterparts. Education and empowerment of women is also essential as these would help the women to lead healthy lives and also help them to keep their families free of diseases. Finally, it is necessary to make maternal health a global health concern and embed it in all health-related programs whether national or global (Apps.who.int 2018).

Thus, maternal health is a serious concern and it should be noted that prevention of maternal mortality is essential in order to prevent negative impacts on the society, family and the economy of a nation and the World in general. Various policies have been applied that helps to curb the consequences of maternal mortality. Although maternal mortality rates have declined in the recent times but still various developing countries are still trying to cope from the maternal mortality issues. One of the most affected regions of the World that is affected by high rates of maternal mortality and also have shown least progress with respect to reduction of maternal deaths are the sub Saharan regions of Africa. Various barriers are also present that prevent the implementations of policies. As a result, various promotional and intervention programs are needed in order to prevent maternal mortality. Thus, this policy brief provides various recommendations that can be used to enhance maternal health in the developing countries, particularly the most affected regions of Africa

Reference List

Ackerson, K. and Zielinski, R., 2017. Factors influencing use of family planning in women living in crisis affected areas of Sub-Saharan Africa: A review of the literature. Midwifery, 54, pp.35-60.

Adedini, S.A., Odimegwu, C., Imasiku, E.N. and Ononokpono, D.N., 2015. Unmet need for family planning: Implication for under-five mortality in nigeria. Journal of health, population, and nutrition, 33(1), p.187.

Apps.who.int (2018). Cite a Website - Cite This For Me. [online] Apps.who.int. Available at: https://apps.who.int/iris/bitstream/10665/75165/1/WHO_RHR_HRP_12.23_eng.pdf [Accessed 20 Jan. 2018].

Apps.who.int (2018). Cite a Website - Cite This For Me. [online] Apps.who.int. Available at: https://apps.who.int/iris/bitstream/10665/153544/1/9789241508483_eng.pdf? [Accessed 20 Jan. 2018].

Assets.publishing.service.gov.uk (2018). Cite a Website - Cite This For Me. [online] Assets.publishing.service.gov.uk. Available at: https://assets.publishing.service.gov.uk/media/57a0899c40f0b6497400018c/Report__Improving_Maternal_and_Newborn_Health_in_Zanzibar_March_2015.pdf [Accessed 20 Jan. 2018].

Benova, L., Cumming, O., Gordon, B.A., Magoma, M. and Campbell, O.M., 2014. Where there is no toilet: water and sanitation environments of domestic and facility births in Tanzania. PloS one, 9(9), p.e106738.

Black, R.E., Levin, C., Walker, N., Chou, D., Liu, L., Temmerman, M. and Group, D.R.A., 2016. Reproductive, maternal, newborn, and child health: key messages from Disease Control Priorities 3rd Edition. The Lancet, 388(10061), pp.2811-2824.

Blencowe, H., Cousens, S., Oestergaard, M.Z., Chou, D., Moller, A.B., Narwal, R., Adler, A., Garcia, C.V., Rohde, S., Say, L. and Lawn, J.E., 2012. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. The Lancet, 379(9832), pp.2162-2172.

Campbell, O.M., Benova, L., Gon, G., Afsana, K. and Cumming, O., 2015. Getting the basic rights–the role of water, sanitation and hygiene in maternal and reproductive health: a conceptual framework. Tropical medicine & international health, 20(3), pp.252-267.

Celik, L.D.C., 2016. Access to contraceptives in Uganda: Approachability, acceptability, and users’ abilities.

Chola, L., McGee, S., Tugendhaft, A., Buchmann, E. and Hofman, K., 2015. Scaling up family planning to reduce maternal and child mortality: the potential costs and benefits of modern contraceptive use in South Africa. PLoS One, 10(6), p.e0130077.

Familyplanning.org.nz (2018). Benefits Of Contraception Use - Family Planning. [online] Familyplanning.org.nz. Available at: https://www.familyplanning.org.nz/news/2013/benefits-of-contraception-use [Accessed 20 Jan. 2018].

Filippi, V., Chou, D., Ronsmans, C., Graham, W. and Say, L., 2016. Levels and causes of maternal mortality and morbidity. Reproductive, Maternal, Newborn, and Child Health, p.51.

Gov.uk (2018). Immpact Key Findings and Policy Implications. - GOV.UK. [online] Gov.uk. Available at: https://www.gov.uk/dfid-research-outputs/immpact-key-findings-and-policy-implications [Accessed 20 Jan. 2018].

Haddou, L. (2018). Maternal mortality down 45% globally, but 33 women an hour are still dying. [online] the Guardian. Available at: https://www.theguardian.com/news/datablog/2014/may/07/maternal-mortality-rate-drops-half-report-who-childbirth-pregnancy [Accessed 20 Jan. 2018].

Johnson, F.A., Frempong-Ainguah, F. and Padmadas, S.S., 2015. Two decades of maternity care fee exemption policies in Ghana: have they benefited the poor?. Health policy and planning, 31(1), pp.46-55.

Kyei-Nimakoh, M., Carolan-Olah, M. and McCann, T.V., 2016. Millennium development Goal 5: progress and challenges in reducing maternal deaths in Ghana. BMC pregnancy and childbirth, 16(1), p.51.

Lshtm.ac.uk (2018). Cite a Website - Cite This For Me. [online] Lshtm.ac.uk. Available at: https://www.lshtm.ac.uk/sites/default/files/2017-07/Policy%20Brief%20-%20WASH%20%26%20MNH.pdf [Accessed 20 Jan. 2018].

Minassian, C., Thomas, S.L., Williams, D.J., Campbell, O. and Smeeth, L., 2013. Acute maternal infection and risk of pre-eclampsia: a population-based case-control study. PloS one, 8(9), p.e73047.

Molla, M., Mitiku, I., Worku, A. and Yamin, A.E., 2015. Impacts of maternal mortality on living children and families: A qualitative study from Butajira, Ethiopia. Reproductive health, 12(1), p.S6.

Ncbi.nlm.nih.gov (2018). Recommendations. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/books/NBK201712/ [Accessed 20 Jan. 2018].

Nnebue, C.C., Ebenebe, U.E., Adogu, P.O., Adinma, E.D., Ifeadike, C.O. and Nwabueze, A.S., 2014. Adequacy of resources for provision of maternal health services at the primary health care level in Nnewi, Nigeria. Nigerian medical journal: journal of the Nigeria Medical Association, 55(3), p.235.

Sahoo, K.C., Hulland, K.R., Caruso, B.A., Swain, R., Freeman, M.C., Panigrahi, P. and Dreibelbis, R., 2015. Sanitation-related psychosocial stress: a grounded theory study of women across the life-course in Odisha, India. Social Science & Medicine, 139, pp.80-89.

Steinmann, P., Bratschi, M.W., Lele, P., Chavan, U., Sundaram, N., Weiss, M.G., Juvekar, S. and Hirve, S., 2015. Availability and satisfactoriness of latrines and hand washing stations in health facilities, and role in health seeking behavior of women: evidence from rural Pune district, India. Journal of Water Sanitation and Hygiene for Development, 5(3), pp.474-482.

Storm, F., Agampodi, S., Eddleston, M., Sørensen, J.B., Konradsen, F. and Rheinländer, T., 2014. Indirect causes of maternal death. The Lancet Global Health, 2(10), p.e566.

Sustainabledevelopment.un.org (2018). Goal 3 .:. Sustainable Development Knowledge Platform. [online] Sustainabledevelopment.un.org. Available at: https://sustainabledevelopment.un.org/sdg3 [Accessed 20 Jan. 2018].

Tran Khanh, T., 2012. ANTENATAL AND DELIVERY CARE UTILIZATIONIN URBAN AND RURAL CONTEXTS IN VIETNAM: A study in two health and demographic surveillance sites (Doctoral dissertation, Nordic School of Public Health NHV Göteborg, Sweden).

Uniteforsight.org (2018). Reproductive Health and Family Planning - Certificate in Maternal and Child Health. [online] Uniteforsight.org. Available at: https://www.uniteforsight.org/women-children-course/reproductive-health [Accessed 20 Jan. 2018].

Usaid.gov (2018). Cite a Website - Cite This For Me. [online] Usaid.gov. Available at: https://www.usaid.gov/sites/default/files/documents/1864/MCHVision.pdf [Accessed 20 Jan. 2018].

Waterfund.go.ke (2018). Cite a Website - Cite This For Me. [online] Waterfund.go.ke. Available at: https://www.waterfund.go.ke/watersource/Downloads/001.%20Sanitation%20and%20Hygiene%20Case%20Study%20Madagascar.pdf [Accessed 20 Jan. 2018].

Waterinstitute.unc.edu (2018). Cite a Website - Cite This For Me. [online] Waterinstitute.unc.edu. Available at: https://waterinstitute.unc.edu/files/2015/06/WPRD-Issue-2-Final.pdf [Accessed 20 Jan. 2018].

Who.int (2018). PMNCH | PMNCH Knowledge Summary #30 Water, sanitation and hygiene - the impact on RMNCH*. [online] Who.int. Available at: https://www.who.int/pmnch/knowledge/publications/summaries/ks30/en/ [Accessed 20 Jan. 2018].

Who.int (2018). WHO | Maternal mortality ratio (per 100 000 live births). [online] Who.int. Available at: https://www.who.int/healthinfo/statistics/indmaternalmortality/en/ [Accessed 20 Jan. 2018].

Who.int (2018). WHO | MDG 5: improve maternal health. [online] Who.int. Available at: https://www.who.int/topics/millennium_development_goals/maternal_health/en/ [Accessed 20 Jan. 2018].

Who.int (2018). WHO | Preventing unsafe abortion. [online] Who.int. Available at: https://www.who.int/reproductivehealth/topics/unsafe_abortion/hrpwork/en/ [Accessed 20 Jan. 2018].

World Health Organization and Unicef, 2014. Trends in maternal mortality: 1990 to 2013: estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division.

World Health Organization, 2015. Trends in maternal mortality: 1990-2015: estimates from WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: executive summary.