A version of this commentary appeared in Policy Options, the Huffington Post and Waterloo Region Record

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Canada has a role to play

The government of Canada recently participated in the G7 Health Ministers meeting in Japan to discuss concrete actions to improve global health.  Among the many issues discussed, improving childbirth outcomes was a critical concern.  Here’s why.

Every day approximately 830 mothers around the world die due to pregnancy and childbirth complications. The vast majority of these deaths occur in African countries and other low- and middle-income countries. What makes this alarming figure even more tragic is that most of these deaths are preventable if women have access to quality healthcare services.

Here’s what the evidence tells us.  The number of mothers that die relative to the number of births — what’s called the mortality maternal ratio — is much higher in low-income countries. In 2015, the maternal mortality ratio in low-income countries was estimated at 239 per 100,000 births compared to 12 per 100,000 in high-income countries.

In fact, maternal mortality can be much higher than this in specific countries within low-income countries due to dramatic disparities in quality and access to services. For instance, in South Sudan the maternal mortality ratio is estimated at 789 maternal deaths per 100,000 births.

By comparison, in Canada, the mortality maternal ratio was 7 per 1000,000 births in 2015, though with significantly higher rates among our indigenous populations.

So what can be done to reduce the gap in maternal mortality and improve maternal health around the world?  Plenty.  And Canada has a large role to play.

Steps have already been taken to identify the problem.

In 2000, the United Nations and more than 23 international organizations, including Canada, adopted an agreement known as The Millennium Development Goals.  The goals address major humanitarian challenges such as reducing extreme poverty, child mortality and improving gender equality.  The fifth goal emphasizes maternal health by improving access to health care services for pregnant women.

In 2010, Canada also spearheaded the MUSKOKA initiative, an investment of $7.3 billion by G8 countries working together to reduce maternal, neonatal and child mortalities globally. Canada itself invested $1.1 billion in the initiative to support low-income nations in their efforts to improve the health of mothers, newborns and children. Canada also committed to 20 projects on the ground with Canadian researchers working alongside African researchers and policy makers to improve access and quality of care to expecting mothers and babies.

Disrepect and Abuse at Health Facilities Needs Attention

Looking forward, Canada could help make a critical difference in maternal health if we worked with other nations and non-profit organizations — specifically to eliminate disrespect and abuse experienced by women at health facilities.


Many important policies addressing maternal mortality focus solely on the lack of available care — too few care facilities or health practitioners, for example, or lack of access to these facilities.  But researchers have found that improving the quality of care is also essential for improving maternal outcomes.

So what needs improvement?

In a meta-analysis on the barriers preventing expecting mothers from seeking care at medical facilities in low and middle income countries, researchers found that care in hospitals and health facilities were often associated with physical and verbal abuse, non-consensual care, discrimination, neglectful care, lack of privacy and even detention against the patients’ will.

These kind of practices in healthcare facilities are referred to as “disrespect and abuse” (D&A) and it can significantly impede the effectiveness of interventions aimed at improving maternal outcomes.

The study found hospital facilities were perceived to be providing too many invasive interventions, such as unnecessary vaginal examinations, that they were insensitive to privacy issues and that they took away women’s control over the birthing process.

Many complained of a lack of supportive attendants at birth during a hospital delivery, some experienced long delays for care, some had a fear of cutting (from episiotomy or caesarean section).  Some women described health providers as verbally abusive, lacking compassion or even physically abusive during delivery.  Other expecting mothers feared compulsory HIV testing or HIV-status disclosure.  And some feared stigmatization because of their unwed status.

Policies that address mistreatment, neglect and abuse in health facilities, and protect the rights of women, could help dispel such distrust and avoidance of health facilities — and improve maternal outcomes in the process.

Around the World there are global civil and professional movements to promote childbirth based on respect and dignity, such as the White Ribbon Alliance. The Alliance convenes individuals, NGOs, professional associations, government entities, youth, community leaders, academics and donor agencies with a common interest in defending the right to a safe birth for every woman.

Now it’s time for Canada to do its part.

As part of Canada’s role as global citizens committed to improving child and maternal outcomes around the world, we should direct our policies, training and funding at tackling disrespect and abuse at health facilities in low and middle income countries.

Canada could do this by initiating more interventions that aim to reduce disrespect and abuse in health facilities, insist on more sensitization training for global health students and NGO workers, and more awareness on the issue for policy makers and health professionals working in the field.  More research on evidence-based policies addressing disrespect and abuse would also go a long way to improve maternal outcomes.

In other words, Canada should be more actively involved in networks that promote a childbirth based on respect and dignity — and save lives in the process.

Of course, in doing this, Canada should work with local practitioners, researchers and policy makers to make sure the work is both based on the best evidence and is culturally appropriate, so we don’t replicate colonial mistakes of the past. And the work on disrespect and abuse should be an integral part of our broader commitment to addressing other barriers to care, such as access to health care services, transportation barriers, health education and more.

The Trudeau government has said that it wants Canada to take a leadership role in global health, including infant and maternal mortality.  Addressing maternal barriers to health care — including eliminating disrespect and abuse from health facilities — is a good place to start.


Loubna Belaid is a postdoctoral researcher at the CRCHUM and the school of public health of the University of Montreal. Her research interests are focused on maternal and reproductive health in low and middle- income countries and she is involved in public health projects related to these issues in Africa and Morocco.

Valery Ridde is an advisor to EvidenceNetwork.ca, an associate professor of global health in the Department of Social and Preventive Medicine and the Research Institute of the University of Montreal School of Public Health (IRSPUM). His research interests are centred around evaluation, global health, healthcare and community-based intervention (www.equitesante.org). He holds a Canadian Institutes of Health Research (CIHR) funded Research Chair in Applied Public Health.

September 2016


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