Obstetric transition

In reproductive health, obstetric transition is a concept around the secular trend of countries gradually shifting from a pattern of high maternal mortality to low maternal mortality, from direct obstetric causes of maternal mortality to indirect causes, aging of maternal population, and moving from the natural history of pregnancy and childbirth to institutionalization of maternity care, medicalization and over medicalization. This concept was originally proposed in the Latin American Association of Reproductive Health Researchers (ALIRH, 2013) in analogy of the epidemiological, demographic and nutritional transitions. In reproductive health, obstetric transition is a concept around the secular trend of countries gradually shifting from a pattern of high maternal mortality to low maternal mortality, from direct obstetric causes of maternal mortality to indirect causes, aging of maternal population, and moving from the natural history of pregnancy and childbirth to institutionalization of maternity care, medicalization and over medicalization. This concept was originally proposed in the Latin American Association of Reproductive Health Researchers (ALIRH, 2013) in analogy of the epidemiological, demographic and nutritional transitions. In the last two decades, the world has seen a substantial reduction of maternal mortality.(1) Considering that maternal mortality is vastly determined by social, societal and contextual factors, this reduction is important not only because of the number of lives that have been spared in this period (an estimated 2,000,000 between 1990 and 2010), but because it denotes that the world is making progress towards development and gender equality.(1,2) However, this progress is still insufficient, unequal and slow: recent estimates suggest that 287,000 women died of causes related to pregnancy and childbirth in 2010. Maternal mortality remains a global tragedy, but the observed progress inspires the international community to believe and strive for the elimination of maternal mortality in the decades to come.(3) The vast majority of maternal deaths is avoidable and takes place in developing countries. In developed countries, the maternal mortality ratio can be as low as 10 maternal deaths per 100,000 live births while among the least developed countries it can be as a high as 1,000 maternal deaths or more per 100,000 live births.(4) This disparity is also observed within countries and when the population is disaggregated in quintiles of income or education.(5-7) Thus, countries, regions within countries and different population groups within country experience a specific momentum in a dynamic process of reduction of maternal mortality, which may benefit from specific approaches. In 1929, Thompson described the phenomenon of demographic transition characterized by a gradual shift from a pattern of high mortality and high fertility to a pattern of low mortality and low fertility.(8) Omram (1971) described the epidemiologic transition, with a shift from a pattern of high prevalence of communicable diseases to a pattern of high prevalence of non-communicable diseases.(9) Finally, Poppkin (1993) proposed the nutritional transition model, which helps to understand the transformations in human diets and the global epidemic of obesity.(10) These transitions and other socioeconomic and cultural changes (e.g. globalization, urbanization) led us to develop the concept of “obstetric transition” (11). As a result of the Millennium Development Goals Project, improved data related to maternal mortality and severe maternal morbidity became available for the period between 1990 and 2010. Altogether, these data reflect a secular trend where countries are gradually shifting from a pattern of high maternal mortality to low maternal mortality, from direct obstetric causes of maternal mortality to indirect causes, moving from the natural history of pregnancy and childbirth to institutionalization of maternity care, medicalization and over medicalization, and aging of maternal population. This is the “obstetric transition” phenomenon, which has implications for the strategies aimed at reducing maternal mortality.