If there’s one thing to be said for the hundreds of maternal deaths that occur every day around the world, it’s that they don’t all have to happen. Looking back at the last 20 years, there has been significant progress: between 2000 and 2017, the maternal mortality ratio (MMR) dropped by about 38% worldwide. But with the pandemic disrupting maternal care in 2020, the global MMR ticked back up from 151 to 152 deaths per 100,000 live births. Of those deaths, mostly all were from preventable or treatable causes.
To get back on track, health officials are pushing for an ambitious global target: By 2030, the MMR should be reduced to less than 70 per 100,000 live births.
With less than 10 years to cut the current ratio by more than half, the global health community, with the support of organizations like Jhpiego, is rallying. Jhpiego is an international non-profit and Johns Hopkins University affiliate that empowers frontline health workers to strengthen the delivery of client-centered health care services for women and their families. Through effective, low-cost, hands-on approaches and solutions, its mission is to help build healthy families, resilient communities, and self-reliant countries. With a sharp focus on deploying 21st-century technologies and data-driven improvements, Jhpiego puts women and families at the center of health care and delivers on the opportunity for a better life for all.
So while the new MMR goal may seem ambitious, it fuels Jhpiego’s expansive team of health and research professionals, including Aissata Ba, a maternal healthcare researcher and program manager with the organization.
How culture impacts care
Ba is originally from Kenya, which has an MMR of about 342 deaths per 100,000 live births. She has seen firsthand what a lack of access to healthcare looks like for expecting mothers and their families. Now working in Mali with Jhpiego’s Antenatal/Postnatal Care Research Collective, Ba is going deeper to help address the underlying factors that contribute to such high death rates in impoverished countries.
“You have to understand that in Mali, because of poverty and the gender power dynamic, many women don’t go for antenatal care,” she says. “Because generally, they don’t have the agency to decide about their reproductive health, like when to have a baby, how to have a baby, and also, when to start going for care.”
Addressing cultural barriers to maternal care is one of the more complex issues to solve because it is one of the most varied. Jhpiego is present in over 35 countries, while the Research Collective, which is funded by the Bill & Melinda Gates Foundation, operates in Ethiopia, Kenya, Malawi, and Mali. Rather than attempting to apply one country’s methods to another, Ba’s research team works to design culturally relevant solutions with each community in mind.
“That’s one of the things I really love about Jhpiego,” she says. “They go about it like, ‘What works in Mali? Let’s ask the people concerned. Let’s ask the pregnant women, the decision-makers, and also the midwife. What are the barriers? What are some of the challenges they face?’”
Convincing decision-makers — usually the pregnant woman’s husband, mother-in-law, or sister-in-law — that antenatal care and postnatal care are worthwhile requires an awareness of specific cultural norms. Beyond that, it also requires that healthcare providers approach these families in a way that makes them feel comfortable about the idea of pursuing professional care.
Concentrating on quality and respect
Early on in Jhpiego’s mission to deploy reproductive health training across the world, its goals were to increase awareness and utilization of health services. Jhpiego’s first efforts in the 1970s were educational: physicians, nurses, and administrators from developing countries had to be made aware of reproductive health breakthroughs. Later, the initiatives evolved into direct training on family planning and reproductive health and improving and strengthening health systems.
Anne Hyre, the project director for the Antenatal Care and Postnatal Care Research Collective, says Jhpiego has achieved most of its early goals.
Countries have more access to training, supplies, equipment, and medications. More than 80 percent of women in lower- and middle-income countries seek out some form of prenatal care, and most women believe it is safer to deliver in a health facility. With these communities more open to the concept of maternal care, the global health community is shifting its focus to something else: quality.
“We have been quite successful with community mobilization — getting people into facilities, understanding the importance of facilities,” Hyre says. “Yet they get there… and the quality of care they get is so poor that they think, ‘Why would I even go back for a third or a fourth visit? What’s the point?’”
Hyre, who has a background as a midwife, has seen that caregivers in these facilities are often overworked and under-valued. Rooms are crowded. There isn’t enough privacy during exams and treatments. All of this contributes to disappointing experiences for patients. Hyre calls it “disrespectful care.” Exhausted providers don’t greet families warmly. Patients aren’t made to feel comfortable. There is often tension and hostility between the women, their families, and the healthcare providers.
In the past, the default solution has been to offer more training to healthcare providers for interactions with patients. While this is one part of the equation to achieving respectful care, Hyre says it’s not the only approach.
“Very often, people are actually trained, but they may be working in an environment where they can’t optimally apply what they know,” she says. “During the training, they may be exposed to very poor quality care and not have a good role model to mimic. You have people who successfully complete training but may lack the confidence to provide a service because they’re very isolated out in a health center working by themself.”
Combatting this demands a deeper understanding of both patient and provider perspectives. Jhpiego is designing human-centered interventions, starting with researching what pregnant women and their families need to feel comfortable. The organization is also working to address the factors that impact healthcare providers.
“I know that the midwives want to be offering good, respectful care, but...it would be very hard to be motivated on a day-to-day basis to go in and treat each other and treat people well in the chaotic and under-resourced environment that they work in,” she says.
Until the factors of stress and anxiety are addressed for both women and care providers, it doesn’t matter how nice a facility looks. This realization is ushering in a new approach to maternal healthcare — one that prioritizes soft skills and mental health.
Mental health and maternal health
Jhpiego employs nurses, midwives, and physicians across the world and is known for its strong team of clinical and technical staff. Even so, Lisa Noguchi says there aren’t enough care providers to serve the populations coming to many health facilities. The WHO is projecting a shortfall of 18 million health workers by 2030.
Noguchi currently serves as Jhpiego’s Director for Maternal Newborn Health, but she has a background as a certified nurse-midwife and epidemiologist. From what she’s seen, she believes health providers are often doing the best they can with what they have, but they’re extremely under-resourced. In some settings where Jhpiego has worked, nurses haven’t been paid for a month or more. Gender plays a role in this; because most nurses and midwives are women, their work and time are seen as less valuable. Working in such an environment has a toll on the mental health of care providers, contributing to depression, anxiety, and post-traumatic stress.
“Health workers, they’re burning out,” she says. “And in many settings, the nurses and doctors, they’re overworked, they’re underpaid, and it’s much harder to provide respectful care when you don’t feel like your contributions are being valued or you’re being asked to do more for less.”
Addressing mental health in maternal health care, whether for mothers or health workers, is a growing area of interest in the countries where Jhpiego operates. Research that leads to evidence-based interventions is one first step to creating successful solutions. With the support of ministries of health, Jhpiego is trying to find holistic ways to identify and address mental health challenges for mothers and their care providers — and working to improve the ways that care is organized and staffed.
Lowering maternal deaths further and faster will require health systems to address all of these challenges: improving women’s experience of health care, addressing the underlying drivers of poor care, and supporting nurses, midwives, and doctors to have healthy work environments.
“When women die in childbirth, it’s often shortsighted to just place blame on the individual health provider,” Noguchi says. “A lot of times, there are a lot of systems failures that have happened along the way.”
Living and working in Mali, Ba is eager to continue Jhpiego’s new approach to maternal care and see how mothers flourish under new systems. She believes that women thrive when antenatal care is warm and invites them to understand what is happening to their bodies.
“My hope is really that the new model we will be developing can not only offer women care but a space where women and healthcare providers can get some relief,” she says.
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To learn more about Jhpiego’s work and donate to help improve maternal healthcare for women worldwide, visit www.jhpiego.org.