Running head: PLACENTA PROTECTION PROGRAM 1

Placenta Protection Program: An Analysis of Maternal Mortality in Developing Nations

Mattie A. Anderton

Legal Studies Academy

Abstract

This paper analyzes the causes behind a high rate of maternal death in the developing

world. The author begins by discussing the history of this issue, discussing the origin of the issue

and past attempts made in an attempt to resolve or lessen its effects. The author further discusses

the current causes of the issue found in disease, complications, unwanted pregnancies,

malnutrition, political turmoil, and lack of access to health services. The author additionally

discusses the legal implications in this issue and possible solutions in order to decrease maternal

mortality in developing countries.

Keywords:​ Maternal, mortality, international, developing, healthcare

Placenta Protection Program: An Analysis of Maternal Mortality in Developing Nations

Over eight-hundred women die in childbirth or due to pregnancy daily, and 99% of the

mothers who die from pregnancy or childbirth are located in developing nations ("Maternal

Mortality," 2018). Millions of babies are left motherless each year due to maternal deaths

(Campbell, n.d.). Infants have less than a 20% chance of survival when their mother dies during

delivery ("Maternal and Child," 2018). Maternal mortality remains a global issue because of lack

of attention, funds, and policy that would reduce mortality rates and assist mothers in isolated

regions in attaining adequate healthcare.

History of Global Maternal Health

During the first half of the 20th century, maternal health was only focused on when

populations were beginning to decline in colonizing areas (Campbell, n.d.). Maternal health was

not seen as an issue needing much attention. Later, during the Cold War era, there was a stark

difference in the way maternal health and mortality was handled in Socialist and

Western-oriented developing countries. During the Cold War, Socialists countries tended to

prioritize health care, and therefore, created maternal health facilities that were widely available

to women, even in rural areas. These services also included abortion services. However, western

developing countries failed to prioritize easy access to maternal health services (Campbell, n.d.).

Worldwide action to reduce maternal deaths began with the 1987 Safe Motherhood

Initiative, which established that steps needed to be taken in order for women to be able to

reproduce and deliver safely and healthily. It particularly focused on women in developing

nations, who are the “poorest of the poor” (B. B. Conable, speech, February 10, 1987). Later, in

2000, the United States added reducing maternal mortality by 75% by the year 2015 to their
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Millenium Development Goals (American Public Health Association, 2011). Although this is in

the United States, a developed nation, it influenced other countries to strive for a reduction in

their maternal mortality rates.

Causes of Maternal Mortality in Developing Nations

There is an abundance of causes for maternal mortality in developing nations. According

to the Kaiser Family Foundation (2018), 27% of maternal mortality is rooted in severe bleeding

that takes place directly post childbirth. Sepsis accounts for 11% of the deaths, followed by

unsafe abortions are 8% and hypertension at 14%. Additionally, diseases such as HIV/AIDS and

Malaria account for 28% of maternal deaths. Further causes include a lack of access to health

services, products, and professionals (Kaiser Family Foundation, 2018).

Diseases

One of the leading causes of maternal mortality in developing nations is diseases. Many

expecting mothers in low-income nations do not receive requisite health care as a result of

stigmas surrounding certain diseases (Magnusson, 2017). One prominent disease observed in

women in these areas is Malaria, which is developed through the bite of infected mosquitoes and

affected 219 million people in the year 2017 (World Health Organization, 2018). Malaria is four

times more likely to infect pregnant women than other adults and can be fatal to both the mother

and her infant (European Alliance Against Malaria, 2007). Another common disease among

pregnant women in developing locations is HIV/AIDS. Pregnant women who test positive for

HIV are eight times more likely to die during pregnancy, childbirth, and the postpartum period

than women who test negative for HIV, and 92% of women who tested HIV positive in 2011

were located in sub-Saharan Africa (United States Agency for International Development, 2017).
PLACENTA PROTECTION PROGRAM 5

The appellate case, ​Minister of Health v. Treatment Action Campaign,​ focuses on the

transmittance of HIV and AIDS between mothers and their infants. The Treatment Action

Campaign (TAC) argued in the original court case that the national Minister of Health and the

government of the Western Cape refused to provide Nevirapine, a drug used around the world

for treating HIV/AIDS and approved by the World Health Organization to combat the

transmitting of HIV from mothers to their children during birth, to the public and failed to set a

goal to create a national program aimed at preventing transmission of HIV between mothers and

their babies. Additionally, the TAC argued that the government needed to create and execute a

program that would effectively prevent the transmitting of HIV from mothers to their babies

(Minister of Health v. Treatment Action Campaign, 2002). The result of this appeal was that the

government must use its resources to create a program that recognizes the rights of pregnant

mothers as well as their babies to have access to proper healthcare and not transmit HIV to the

babies if preventable. In addition, the program must have counseling for pregnant women, HIV

tests for pregnant women, and efficient treatment and counseling for HIV positive pregnant

women. Following the previous case, the government failed to follow through with all of their

responsibilities deemed by the court. For example, doctors in public health centers had no ability

to prescribe Nevirapine. The government was told they must eliminate any barrier preventing the

availability of Nevirapine at public health centers, allow the prescription of Nevirapine, train

counselors at public centers for HIV positive mothers, and expand the testing of pregnant women

for HIV (Minister of Health v. Treatment Action Campaign, 2002).

Pregnancy-Related Complications
PLACENTA PROTECTION PROGRAM 6

Women in developing countries also face maternal mortality as a result of

pregnancy-related complications. Placenta previa, when the placenta is low in the uterus and

covers the cervix, causing the placenta to separate from the uterine wall, also known as Abruptio

placentae, is one major pregnancy-related complication (American Pregnancy Association, n.d.).

Another complication is multiple gestations or having twins, triplets, etc., wherein a study of

4,049 pregnant women, eighty-eight of them were multiple gestations and only 38% of mothers’

had all of their babies live past one year. Additionally, multiple gestations were said to have

contributed to 11.5% of the maternal deaths out of the 4,049 (McDermott, Steketee, & Wirima,

1995). Intrauterine growth restriction (IUGR) is a further pregnancy-related complication where

the fetus is smaller than it is supposed to be at a certain point in the pregnancy, caused by a lack

of growth of the cells and tissues due to a mother’s high blood pressure, disease, malnutrition,

infection, or substance abuse (Stanford Children’s Health, n.d.). Eclampsia is an additional

complication, and it is the onset of seizures or coma in pregnant women (U.S. National Library

of Medicine, 2018). 76,000 pregnant women die from preeclampsia around the world each year,

and women in developing nations are seven times more likely to get preeclampsia than women in

developed countries (Preeclampsia Foundation, 2013). Shoulder dystocia, when the fetus’s

shoulder is pushed against the mother’s pubic symphysis, may generate dangerous heavy

bleeding and lacerations for the mother (Baxley & Gobbo, 2004).

Unwanted Pregnancies

Unwanted pregnancies and unsafe abortions lead to a high rate of maternal mortality in

developing nations especially. Forty-two million pregnant women each year choose to have an

abortion, and about half of these abortions are unsafe, leading to about 68,000 women dying each
PLACENTA PROTECTION PROGRAM 7

year due to these unsafe procedures. 97% of these unsafe abortions take place in developing

nations (Haddad & Nour, 2009). Unsafe abortion is defined as “a procedure for terminating an

unintended pregnancy carried out either by persons lacking the necessary skills or in an

environment that does not conform to minimal medical standards or both” (Haddad & Nour,

2009). Essentially, these procedures are done without a health professional, and not in an

adequate facility with the essential equipment needed to safely carry it out. In Western nations,

3% of abortions that take place are considered to be unsafe, yet 55% of abortions in developing

nations are considered to be unsafe. Methods of unsafe abortion include drinking toxic fluids,

inflicting injury to the vagina or cervix, inserting a foreign object such as a coat hanger or bone

into the uterus, taking harmful medication directly via the vagina or rectum, or causing external

injury to the body by ways such as jumping from a roof or imposing trauma to the abdomen.

(Haddad & Nour, 2009).

Maternal Malnutrition

Maternal malnutrition is another chief cause of mortality amongst women in developing

nations. A lack of food resources, poor diets, infections such as HIV and AIDS, and short periods

between pregnancies leads to maternal malnutrition. In Africa, 5% to 20% of women have a low

BMI due to chronic hunger (Schwartz, 2013). Diets in developing nations are typically missing

proteins, carbohydrates, and fats that are needed to stay healthy. Poverty is the foremost origin of

malnutrition, and between the years of 2000 and 2002, 815 million of the 852 million people

who were undernourished were located in developing areas (Muller & Krawinkel, 2005).

Political Turmoil
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Political turmoil is a fundamental contributor to high rates of maternal mortality in

underdeveloped countries. Beginning with the effect of war on pregnant women, armed conflict

is a major cause of a lack of access to maternal and reproductive health services, as money is

short and transportation is inadequate due to it being a large risk to travel anywhere. Besides not

having access to proper medical care, there are accounts of first-hand assaults on pregnant

women in war zones, such as a woman being shot in Nigeria while delivering her baby, and a

baby being shot through a woman’s womb in Syria (Sohn, 2016). Doctors and midwives

evacuate the area of dangerous conflict, running water turns scarce, and violence against women

increases (Sohn, 2016). Migration and being forced into refugee status due to political turmoil

also has a grave effect on mothers. According to Sidelemine (2018), lack of language skills

create a barrier to immigrant and refugee women, and linguistic barriers prevent these women

from access to health services that they need. Sexual abuse in refugee camps and an increase in

sex tourism and prostitution as a result of migration increase the amount of Sexually Transmitted

Diseases, which affects pregnant women and their infants (Schwartz, 2013). However, despite a

large amount of sexual abuse fostering a higher amount of unwanted pregnancies or threatening

STDs, the law established by the Convention on the Elimination of All Forms of Discrimination

Against Women is violated by this act (Magnusson, 2017).

Lack of Health Services

Facilities. ​Women in developing nations have a notable lack of access to health services.

In rural areas, facilities may have only basic equipment for minor treatments, and pregnant

women have no way to reach another facility with adequate equipment and skilled professionals

(Thaddeus & Maine, 1994). WHO proposes there should be four or more facilities with basic
PLACENTA PROTECTION PROGRAM 9

emergency obstetric care (EmOC) and one facility with comprehensive EmOC per every

500,000 people (Prata, Passano, Sreenivas, & Gerdts, 2010). Basic EmOC provides medical help

that does not involve surgery such as manual removal of the placenta, supplying antibiotics, and

vaginal delivery. Comprehensive EmOC provides the same as basic, with the addition of

cesarean sections and blood transfusions (Prata, et al., 2010).

Geographical distribution. ​There are certain governmental systems arranged in

developing and rural areas that lead to a higher rate of maternal mortality, one of these being the

unequal geographic distribution of health facilities capable of allocating certain maternal health

emergency or preventative services. In the case of ​Alyne de Silva Pimentel v. Brazil​, the United

Nations Committee on the Elimination of Discrimination against Women (CEDAW) instituted

that it is a violation of the human rights of people for a government to not provide all women in

their country equal access to attainable and adequate maternal health services (Alyne Da Silva

Pimentel v. Brazil, 2007). Alyne de Silve Pimentel passed away due to not arriving at a health

facility in a timely manner, not receiving necessary diagnostic tests, and not receiving surgery to

remove her placenta after she gave birth to a stillborn. All of these issues were a direct result of

the unequal geographic distribution of healthcare provisions (Magnusson, 2017).

Health workers. ​Professional health workers being present at the time of the birth

increases the chance of both the mother and the infant’s survival. When mothers deliver at home

without a professional, maternal mortality is at an average of 500-1,000 per every 100,000. In

contrast, mothers who deliver with a professional caregiver such as a doctor or midwife, the ratio

may drop to fifty per every 100,000 births resulting in maternal death, despite the location of the

birth (hospital, home, etc.) (Campbell, n.d.). Less than 50% of women in the poorest countries
PLACENTA PROTECTION PROGRAM 10

deliver their infants in the presence of a medically trained professional (Paruzzalo, Mehra, Kes,

Ashbaugh, n.d.). The number of nurses and midwives in Africa is eleven per every ten thousand

people in a population, versus seventy-nine per every ten thousand people in Europe (Prata, et

al., 2010). According to the Africa Progress Panel (2010), there are fifty-seven developing

countries who have a deficiency of skilled health workers, and over two million workers are

needed.

Costs. ​Costs for pregnancy and delivery include the hard-hitting price of drugs and other

needed equipment, transportation to a medical center, and payment of a medical professional. In

the poorest households, these costs were more than 40% of the total annual income of the

household, and the cost of emergency care when something goes wrong, which is more likely to

happen in poorer areas, is substantially higher (Paruzzalo, Mehra, Kes, Ashbaugh, n.d.). A

survey of mothers in West Africa showed that over half of the woman did not seek healthcare

due to cost (African Progress Panel, 2010).

Underdeveloped governments have made various attempts to help combat the

issue of cost as a cause of maternal mortality. For example, Ecuador passed a law in the year

1994 that granted all women free maternal health care. It covered delivery services, postnatal,

and the ability to enroll in programs regarding information on reproductive health (Magnusson,

2017). The law pulls funds from taxes and various levels of governments in order to sponsor the

overbearing costs of treatments, tests, medicines, and supplies to ensure safe pregnancies. Under

this act, the government would provide for all antenatal visits, STD treatment, the coverage of

both vaginal deliveries and surgical ones, emergencies, delivery care, and postnatal care

(Magnusson, 2017). If each developing country had the means, funds, and resources to
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implement laws such as this one, maternal mortality could drop drastically. It is especially

important for nations lacking a national health care scheme to focus on developing laws that will

protect expecting mothers. It is common that private health insurance contracts exclude maternal

services such as antenatal care or birth attendants, and mothers are either unaware of this or

cannot afford the insurance packages that would include this (Magnusson, 2017).

Medicines and equipment. ​There are crucial medications needed that are not provided

in developing nations for pregnant women. Only a mere 33% of needed medications are

obtainable in developing countries (Prata, et al., 2010). To reduce the risk of mothers bleeding

out, they can be injected with Oxytocin directly after birth, and they can be given drugs such as

magnesium sulfate to lessen the risk of eclampsia or high blood pressure (World Health

Organization, 2018). Birthing facilities need to have sterile instruments, antibiotics, blood, and

iv. Fluids on hand for the case of puerperal sepsis. They also need a partograph, which monitors

fetal presentation, head engagement, fetal heart sounds, and ascertains if the mother is showing

signs of obstructed or prolonged labor, which would precede the call for an artificial rupture

(Prata, et al., 2010).

Transportation and infrastructure. ​Developing nations are often geographically

isolated, thus making health facilities far away and difficult to travel to. Roads can be either

nonexistent or in substandard shape from poor quality or weather incidents. In rural Zimbabwe,

28% of maternal deaths were caused by issues involving transportation (African Progress Panel,

2010). Countries continuously ignore the need for further development in roads or providing

substitute methods of transportation, leading women to attempt walking or biking to facilities. A

woman in labor in Ghana waited for over three hours for an ambulance to reach her, and despite
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gaining access to free maternal health care, deaths have hardly lessened because there is no

means to get to health facilities. In many instances, mothers will be referred to other health

facilities due to their needs for more intense care, but 70% of these referrals are not upheld as

there is no mode of transportation available (Atuoye, Dixon, Rishworth, Galaa, Boamah,

Luginaah, 2015).

Information deficit. ​It is hard to tell exactly how high maternal mortality rates are in the

developing world due to a lack of surveillance and statistical reporting. About 40 million people

die each year unregistered, and many developing countries use inaccurate surveys conducted by

family members to gather data on maternal deaths (African Progress Panel, 2010). In many

cases, it is difficult to identify and record female deaths and how many of these deaths are

prompted by pregnancy. According to the Magnusson (2017), governments should, in fact, be

overlooking and collecting data on the health services provided to ensure pregnant women

undergo a safe and healthy term, including monitoring prenatal appointments, the appointment of

skilled health workers to births, and postnatal appointments.

Laws and Rights Around the World

The international community has made attempts at combating maternal mortality

globally, and more specifically, in the developing world. If made widespread, enforced more

strictly, and funded properly, these attempts could make major improvements at reducing the

high rate of pregnant women’s deaths.

International Policy

According to Magnusson (2017), women have a right to healthcare that is high in

standard and attainable. The Universal Declaration of Human Rights pronounces that
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“motherhood and childhood are entitled to special care and assistance.” This means that mothers

have individual needs involving the health they receive and that countries have an obligation to

adhere to these needs. Furthermore, the Convention on the Elimination of All Forms of

Discrimination against Women upholds that countries must recognize the unique health needs of

pregnant women and satisfy them with any necessary measures in order to ensure a healthy

pregnancy (Magnusson, 2017).

Uganda’s Attempt

Uganda is considered to be one of the least developed countries in the world (Kulabako,

2009). The Constitution, however, states that the country has an obligation to bestow any and all

services that will forward the natural maternal functions of women. The government also, by

word of the Constitution, must confront prejudices found in their healthcare system and put forth

any resources necessary in order to fulfill their Constitutional obligations towards mothers.

These provisions in Uganda are enforceable by the court (Magnusson, 2017).

Ghana

In 2004, Ghana began a free delivery care program for all women that was funded by

debt repayments to the government. As it covered all institutional costs of birth, it escalated the

number of deliveries taking place at health facilities which made birth overall safer. In 2007 it

was replaced by the National Health Insurance Scheme (NHIS), making it so women not

enrolled in this scheme had to pay for their baby delivery costs. Later, in 2008, Ghana exempted

all pregnant women from paying health insurance premiums, which influenced women to join

the NHIS. This provided the women of Ghana with antenatal care, free delivery, Caesarean
PLACENTA PROTECTION PROGRAM 14

Sections as needed, the treatment of emergency conditions, and postnatal care (Africa Progress

Panel, 2010).

A Comparison Between the Developed and the Developing

According to Magnusson (2017), pregnant women in the developing world have a twenty

times higher chance of dying during the delivery of their infant than in the developed world.

Women in developed countries have at least four antenatal visits, yet less than half of pregnant

women in undeveloped countries had any (Maternal Mortality, 2018). According to the Kaiser

Family Foundation (2018), the number of maternal deaths per every 100,000 births in the year

2015 was 555 deaths per every 100,000 births in sub-Saharan Africa, compared to thirteen deaths

per every 100,000 births in both Europe and North America. Additionally, the percentage of

births in sub-Saharan Africa attended by a skilled healthcare professional was a mere 57.8%

compared to America’s 99.0% and Europe’s 99.1% (Kaiser Family Foundation, 2018).

To show a comparison between developing nations and the United States, a developed

country, an example of a Colorado health care policy may be used. This law ensures obligatory

coverage for women’s health insurance in Colorado, stating that maternal care in pregnancy and

childbirth, as well as contraceptives, shall be covered by the state in the same way as it would

cover any other illness or condition (Magnusson, 2017). In this way, the state ensures that

women face no obstructions in an attempt to obtain the services they need for a healthy

pregnancy and delivery, and this law can serve as a model for potential legislation in low-income

countries.

In recent months, the United States has additionally signed a law that will verify that all

areas of the country have attainable access to health workers. This law is known as the
PLACENTA PROTECTION PROGRAM 15

Improving Access to Maternity Care Act. With the implementation of this act, the Health

Resources and Services Administration will be obligated to pinpoint localities with a deficiency

of maternal health professionals and further designate professionals to those specific regions

(Improving Access, 2018). As the developing world has major unavailability of skilled health

workers, it still lacks laws like this one to increase birth attendant deliveries.

Solutions

Professional Caregivers

Having the presence of a professional caregiver at the time of delivery is crucial to

decreasing maternal mortality in the developing world. Millions of births happen without a

trained midwife, nurse, or doctor present (Maternal Mortality, 2018). To increase the number of

skilled health professionals in developing nations, the governments and supporting developed

countries can provide worthwhile incentives for rural postings, which are job assignments in

rural areas abroad (Campbell, n.d.).

Additionally, maternity waiting homes may be established. These are close to health

facilities, where mothers go when they are close to term in order to be closer to a safe place to

deliver than her home is. In developing nations, low-level staff such as nurses and midwives may

be trained to perform life-saving high-level operations such as a Cesarean Section or surgically

removing the placenta in order to reduce the need for doctors (Campbell, n.d.). Tunisia reduced

maternal mortality by about 80%, and this is believed to be the most influenced by the increase

in skilled healthcare providers at the time of birth (Africa Progress Panel, 2010).

Access to Antenatal Care

Antenatal care is a way in which women can know early on in their pregnancy whether

they have life-threatening or concerning afflictions. These afflictions include sexually

transmitted diseases, hypertension, and fetal malpresentation (Prata, et al., 2010). Certain

medications and treatments may be offered during these prenatal visits in order to prevent or

reduce the risk of mortality or having serious health effects. For example, magnesium sulfate can

be given to expecting mothers early on in order to not develop life-threatening Eclampsia

("Maternal Mortality," 2018).

Family Planning

Despite the fact that they are the least capable of maintaining and providing for high

populations, low-income nations hold the globe’s highest rate of population growth (DaVanzo &

Adamson, 1998). Family planning programs supply women with access to more information

about their bodies and pregnancy, counseling, and contraceptives. With the addition of these

forms of contraceptives, information, and assistance, unwanted pregnancies, unsafe abortions,

and thus maternal mortality is lessened (Prata, et al., 2010). In countries such as Hungary and

South Korea, abortions, which are risky operations, lessened after the use of contraception

heightened, and family planning allowed women to get pregnant later and with more time

between each child in order to ensure their body is physically ready for it (DaVanzo & Adamson,

1998). In developing nations with the lowest income, family planning is proven to be a service

that saves the most maternal lives (Prata, et al., 2010). According to the World Health

Organization, over 200 million women around the world do not have access to necessary

contraceptives, and in Africa, 23% of women within the reproductive age do not have access
PLACENTA PROTECTION PROGRAM 17

(Magnusson, 2017). Family planning programs such as diagnostics and treatment for STDs and

women’s ability to control their fertility would have a mass reduction on maternal mortality.

Legal Solutions

Legislation providing for the welfare of mothers in the developing world can be scarce,

but many of the solutions to reducing the mortality rate are found in developing and enforcing

new laws and policies. There are many examples as to what these pieces of legislation could be

modeled after according to Magnusson (2017). Referring back to the idea of maternal waiting

homes, laws should be put in place in order to develop more of these free spaces with meals,

lodging, and equal access for all women despite economic status or geographic location. When

speaking on health insurance, governments should instruct that all plans should contain coverage

over vital maternal health needs (Magnusson, 2017).

Conclusion

In order to reduce maternal mortality in isolated regions and the developing world,

pregnant women in this area must be given the opportunity to obtain adequate maternity health

care. Legislation protecting women’s universal right to a high standard of maternal health

services must be implemented and funds must be allocated to the cause. It must be a global effort

in order to lessen the strong effect that maternal death has on developing countries. Rural areas

and low-income nations must develop the capability to provide women with sufficient health

services, facilities, equipment, transportation, skilled personnel, and emergency and preventative

care.
PLACENTA PROTECTION PROGRAM 18

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