Maternal health: A pending task at the global level

Salud materna


Drastically reducing maternal mortality worldwide is one of the development goals proposed for 2030 that isn’t on track. But it’s becoming increasingly clear that, for those women who survive giving birth, specific attention for them is also necessary. Mental health is of particular concern, and it goes beyond the well-known postpartum depression.

Some 290,000 women died worldwide in 2020 from causes related to pregnancy and childbirth: one every two minutes. The maternal mortality ratio, measured between pregnancy and the first six weeks postpartum, was 223 per 100,000 births that year.

The gap between high- and low-income countries is gargantuan – 12 versus 430 per 100,000, on average – and 95% of deaths occur in low- or lower-middle-income nations. Depending on what part of the world those women are in, it’s not just the numbers that change. The causes behind these deaths are also different. From difficulty accessing health services due to long distances, not having money when care isn’t subsidized, or a lack of qualified personnel, to inexistant protocols for monitoring women throughout the different stages of pregnancy or hardly giving any attention to their mental health.

Wealthy countries

In Spain, the maternal mortality rate is 3.26 mothers per 100,000 live births, one of the lowest in Europe. Norway stands at 2.7 and Denmark comes in at 3.4, according to a study that covers eight European countries. In Poland, that number is 2, according to WHO data.

In the UK, 229 women died from 2018 to 2020 between pregnancy and the sixth week after childbirth, which is 10.9 deaths per 100,000 births: a number that has increased 24% compared to the previous three-year period, according to University of Oxford’s MBRRACE research program. Inequalities come to light here too: compared to white women, Black women are nearly four times more likely to die, while Asian women are twice as likely.

What’s more, 289 mothers died in the UK between the sixth week and first year after giving birth. 38% of these deaths were related to mental health issues, with suicide as the leading cause. Compared to the previous period (2017-19), in 2020, women were three times more likely to die by suicide during pregnancy and up to the sixth week postpartum.

In developed countries, one in 10 mothers suffer from a mental health problem during pregnancy or in the year following childbirth

In other countries, the data on mental disorders related to childbirth paints a similar picture. In the United States, where in the last two decades maternal deaths have risen from 12 to 21 per 100,000 live births, according to The Wall Street Journal, one in seven women suffered from depression during pregnancy or after giving birth. According to the US health authorities, “almost a quarter of deaths occur before the end of pregnancy, related to suicide or overdose; a quarter on the day of delivery and half in the following year (hemorrhaging, heart problems, etc.)”. The maternity mortality rate for Black women is more than double the average rate and nearly triple that of white women.

Red alert for mothers’ mental health

In September 2022, WHO published its new guide for integration of perinatal mental health in maternal and child health services. According to the report, 1 in 10 women in high-income countries suffer from a mental health problem during pregnancy or in the year following childbirth, and 1 in 5 mothers in lower-income countries. And among women with postnatal mental health problems, 20% have suicidal thoughts or self-harm.

The report adds that such thoughts do not always lead to plans to kill oneself, although warning signs are exhibited in many people who attempt it. It also notes that some have suicidal thoughts or behaviors without a prior mental health problem. In addition, it is not an exclusively female problem: a study in The Lancet shows that, globally, up to 10% of fathers suffer from a common mental disorder during the postpartum period.

Before discharging a woman who’s just become a mother (and in check-up visits during the following weeks), in addition to checking how her physical recovery is progressing and how breastfeeding is going, it is essential to talk about the psychological and emotional changes they may be going through, and explain that feelings of sadness that generally appear in the first days after giving birth are normal and within what can be expected.

Commonly known as the baby blues, it’s a short-lived state of sadness, tiredness, irritability or little appetite that between 50% and 70% of mothers suffer from between the second and fourth day after giving birth, due to biological changes, and it usually disappears within two weeks. If the symptoms last longer or start later, it could be postpartum depression.

Stress and anxiety

The UK National Health System (NHS) reports that perinata mental illness occurs in more than a quarter of mothers who are pregnant or have just given birth. In particular, between 10 and 15 women out of every 100 suffer from postpartum depression, and in a third of them the symptoms had started during pregnancy.

Although they can sometimes occur together, PTSD after childbirth is different from depression. According to one study, between 3% and 6% of women suffer from it after giving birth, although many more go undiagnosed.

Postnatal anxiety is less talked about, but it’s more prevalent than depression in some countries, according to studies. In a survey of 16,000 women who had given birth in the UK in 2017, 29% said they had suffered from anxiety and 16% from postpartum depression. In a study out of Canada, 17% of women surveyed presented postpartum anxiety, compared to 5% who suffered from depression. And there are even less well-known disorders among new mothers: between 2% and 3% may suffer from postnatal obsessive-compulsive disorder (OCD).

More mother-baby units

Puerperal psychosis or postpartum psychosis is much less common, affecting one in 500 new mothers. But it is also much more serious. It consists of a combination of bipolar-like symptoms, delusions, and hallucinations that can be life-threatening for both the mother and baby. The most severe symptoms can last from two to twelve weeks and recovery usually takes six to twelve months (although sometimes longer). Women who suffer from it are usually admitted for treatment.

In the UK there are 22 special psychiatric units for mothers and babies (Mother and Baby Unit, MBU), where they can stay together. They treat cases of postpartum psychosis, but also women with existing disorders and severe cases of postpartum anxiety, postpartum depression and postpartum OCD.

According to the Royal College of Psychiatrist, only between two and four women in every 1,000 who have a baby need to be admitted for a mental health problem. But even so, in the United Kingdom efforts are being made to increase patient capacity in the MBUs, because there isn’t enough. And if there is no special unit nearby, or if the beds are occupied, the only solution left is for the woman to be admitted to the psychiatric ward of the nearest hospital; but in these cases, the baby has to stay with their father or another relative (or with a foster family if there is no one other than the mother who can take care of them).

Long maternity leave prevents or reduces the stress associated with childbirth and breastfeeding, and contributes to postpartum recovery

In Spain there aren’t any mother-baby units like the British MBUs. The closest thing is the Hospital Clínic de Barcelona’s partial hospitalization service which has been operating since 2018, with capacity to care for between 50 and 60 mothers a year.

Early action

Outside the health sector, a study published in The Lancet in January 2023 underlines that longer and paid maternity leave is beneficial for the mental health of mothers: both factors prevent or reduce the stress associated with childbirth and breastfeeding, contribute to the woman’s recovery after childbirth and help prolong breastfeeding (which in turn can promote bonding with the baby).

If, in addition, both parents can enjoy paid leave, stress due to financial and job uncertainty is reduced, and the balance between professional and family life benefits. It’s true that, when analyzing the impact of paternity leave on fathers’ mental health, there are positive effects, but the results aren’t as conclusive as when it comes to mothers. However, studies out of several counties show that their parental leave does appear to be beneficial for the mothers’ mental health.

When it comes to preventative mental health, there’s also a long way to go. In Spain, where postpartum depression affects one in 10 women, “since 2018, only the pregnancy monitoring protocol in Catalonia includes mental health screening as part of the three check-ups with midwives” throughout a pregnancy and postpartum, according to El País.

The effectiveness of midwives

Precisely, this care by midwives is essential. On its website, the European Institute of Perinatal Mental Health cites a study out of Canada “where care by midwives and not by specialists proved to be effective in reducing premature births and complications in the perinatal stage.” And another, carried out in Spain, reveals that attending a breastfeeding support group can reduce visits to the pediatrician by 50%.

But an additional 900,000 midwives are needed worldwide, as the United Nations Population Fund recently noted, if the UN’s goal of reducing the global maternal mortality rate to less than 70 deaths per 100,000 live births is to be reached between now and 2030 (the current number is 223 deaths).

In Spain, 5,000 midwives are needed “to reach the average ratio, according to data provided by the OECD, and to match the ratios in developed countries,” Antonio Morillas, vice president of the Midwives Associations Federation of Spain (FAME), said in a statement to ABC. Currently there are 6.1 midwives for every 10,000 women of childbearing age. The average in Europe is 9.1. If this number is achieved, explains Morillas, in the delivery rooms the woman giving birth would always be attended to by a midwife, and its’s been shown, that “this reduces obstetric complications and the medicalization of childbirth, which generates a positive experience and better bonds between the mother and the newborn.”

However, in a survey by the University of Oxford in 34 countries that are part of the European Federation of Psychiatric Trainees, it turned out that only six of them have specialized training in postnatal mental health. One more task to add to the to-do list to help prevent a mother from dying every two minutes.

Translated from Spanish by Lucia K. Maher

Contenido exclusivo para suscriptores de Aceprensa

Estás intentando acceder a una funcionalidad premium.

Si ya eres suscriptor conéctate a tu cuenta. Si aún no lo eres, disfruta de esta y otras ventajas suscribiéndote a Aceprensa.

Funcionalidad exclusiva para suscriptores de Aceprensa

Estás intentando acceder a una funcionalidad premium.

Si ya eres suscriptor conéctate a tu cuenta para poder comentar. Si aún no lo eres, disfruta de esta y otras ventajas suscribiéndote a Aceprensa.