1000 Days and 1000 nights – Time to make childbirth safer

In 2007, I was surprised by an invitation to take on a two-year assignment at the World Health Organization. The offer was to join the recently convened WHO World Alliance for Patient Safety. I was excited, and the timing seemed good. I could take a sabbatical from my University position, and my wife was still on maternal leave following the birth of our son. We imagined he could attend a neighborhood école maternelle in Geneva and learn French.

As the time approached to pack up and move, our family got unexpected news – my wife was again pregnant. This meant that a baby would be arriving that winter - who would be born far from the familiar care of our physicians at Johns Hopkins.

Some of our friends and family were worried. “You’re not going to have your baby in Switzerland, are you?” The assumption was that care in the US would be better. It struck them as risky to deliver a baby abroad.

It didn’t take much research to uncover that the maternal mortality rate in Switzerland was the lowest among the 37 Organisation for Economic Co-operation and Development (OECD) member countries. At 1.4 deaths per 100,000 births, the maternal death rate was 7 times lower than in the US. ¹ And infant mortality in the first year of life was two-and-a-half times higher in the US than in the top-ranked OECD country (Iceland).

Today the US still lags behind other OECD nations in maternal and infant mortality rates. But the situation is far worse elsewhere. There are more than 130 million births a year, and women and babies around the world suffer an enormous burden of avoidable harm around childbirth.

Childbirth is the number two killer of women of childbearing age. Women are most commonly harmed by excessive blood loss, infection, high blood pressure (eclampsia), obstructed labor, and complications after unsafe abortion. In 2017 there were 2,95,000 maternal deaths, 94% of them occurring in low-income countries. ² In low-income countries, the rate was 462 per 1,00,000 live births, compared to 11 in high-income countries. In South Sudan, the rate was 1150. Because women in less developed countries tend to have more pregnancies than women in developed countries, their lifetime risk of maternal death is higher. The probability is that 1 in 45 women will die from a maternal cause.

Examining newborn mortality, there were 2.6 million stillbirths, and 2.7 million deaths within 28 days after birth. ³ The most common causes are infections, preterm birth, and birth asphyxia. The neonatal period is the time of greatest risk. About a third of all neonatal death occur within the first day after birth, and nearly three-quarters occur within the first week of life. Most of these deaths are in low-income countries. ⁴

The great majority of these deaths are preventable. Up to two thirds of newborn deathes can be prevented by known effective measures provided at birth and during the first week of life. Skilled care before, during and after childbirth can save lives of both mothers of infants.

As part of WHO’s efforts to address the major causes of maternal and neonatal death, the Safe Childbirth Checklist programme was established, in collaboration with physicians, nurses, midwives, experts and patients worldwide.^3,5 The 28-item Checklist consists of evidence-based practices such as handwashing and use of clean gloves, monitoring of the woman’s blood pressure, and provision of uterine massage and medication to prevent hemorrhage. These practices are organized into four pause points: on admission, just before pushing (or before cesarean section), within 1 hour after birth, and before discharge. Use of the checklist was shown to significantly improve use of essential birth practices by birth attendants. ⁶

However, use of the Checklist did not reduce stillbirths, newborn or maternal mortality in a large multi-centered trial in north India. ⁶ More work is needed to improve the quality of care around childbirth. Simply providing skilled care to mothers during pregnancy, during and after birth would contribute greatly. But families and communities concerned about the quality of local services may still need to be convinced that such care is needed. And there is a continued need identify additional factors that can save lives in childbirth and to improve systems to address them.

In this issue, a paper by McCarthy and colleagues ⁷ acknowledges the ever-present risk of serious morbidity and mortality in childbirth care. Even in high income countries, obstetric emergencies will inevitably present themselves. There is the need for health providers worldwide who care for these women to be trained to manage these scenarios, which are generally unanticipated

A paper by Lake and colleagues describes their handling of a different kind of emergency – the potential for an oxygen shortage precipitated by the COVID-19 pandemic. ⁸ Although very different from maternal care, their work also highlights the benefits of contingency planning.

Myers and colleagues argue that preparing for healthcare crises requires building physicians’ business management abilities. ⁹ They use the current COVID-19 crisis to demonstrate the importance of having knowledge and skills in areas such as health finance, collaborative leadership and managing change.

It is compelling to focus the first 1,000 days of life – the time between the conception of a woman’s pregnancy and her child’s second birthday. This period offers a unique opportunity to improve the odds of future health and well-being. ¹⁰ Too often, however, especially in developing countries, poverty and related conditions lead to early mortality and important morbidities. A focus on maternal and newborn safety are critical to getting a strong start in those first 1000 days.

With that in mind, the WHO Patient Safety Flagship has chosen maternal and newborn safety to be the theme of World Patient Safety Day 2021. Since 2019, this important occasion is observed annually on 17 September as a World Health Assembly mandated global health day. Participation and commitment to this theme will help newborn babies and their mothers get the attention they deserve.