Editorial

The Sustainable Development Goals (SDGs) are known officially as Transforming our world: the 2030 Agenda for Sustainable Development. The SDGs consist of 17 goals and 169 targets to be achieved by 2030,¹ covering a broad range of issues, including food security, nutrition, health and education. The agenda recognises non-communicable diseases (NCDs) as a major challenge for sustainable development,² and the global community has identified NCDs as an emerging priority to advance women’s health and development.³ Not surprisingly, the proposed Ending Preventable Maternal Mortality strategic framework draws attention to chronic NCDs and social determinants that contribute to maternal mortality.⁴

Obstetric Medicine has a critical role to play in achieving the SDGs. As a specialty, we manage women with pre-existing chronic illnesses that constitute the NCDs, as well as such chronic illnesses that happen to present in pregnancy. Also, we manage women who develop illnesses that arise as a direct result of pregnancy but that may herald the onset of NCDs in later life.

At the 2014 International Society of Obstetric Medicine (ISOM) meeting in New Orleans, a panel on Global Obstetric Medicine generated tremendous interest and enthusiasm. This fuelled creation of a joint International Society for the Study of Hypertension in Pregnancy (ISSHP)/ISOM Global Health Committee, as well as plans for this special issue that address key concepts and themes in global obstetric medicine.

The first and second papers address the incidence and nature of direct and indirect maternal deaths on a global scale. von Dadelszen and Magee address the causes of direct maternal death (i.e. of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management). Of the five leading causes globally, the obstetric internist can play an important, specific role in managing the balance between coagulopathy and elevated thromboembolic risk in postpartum haemorrhage, multiple aspects of the care of women with pregnancy hypertension, and for obstetric sepsis, promotion of the ‘Sepsis Six’ bundle and appropriate empiric or targeted antibiotic therapy and fluid resuscitation. While these activities may serve to improve outcomes related to direct obstetric causes of death, as well as build a foundation for expansion of care of medical co-morbidities that should further decrease death from direct and indirect obstetric causes, the fact remains that health advocacy and a focus on the social determinants of health will be necessary if we are to achieve SDG 3.1 – a reduction by 2030 in the global maternal mortality ratio from 196 to <70 per 100,000 live births.

Nair et al. address indirect maternal deaths (i.e. resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by physiologic effects of pregnancy) that now represent 25% of global maternal deaths, and the rate is rising. The causes of indirect death include a range of communicable diseases, NCDs and nutritional disorders. Evidence of transition from direct to indirect maternal deaths due to an increase in NCDs among women in the reproductive age range has been observed in many low-and-middle-income countries. The gaps in care identified include poor access to health services, lack of health care providers, delay in diagnosis or misdiagnosis and inadequate follow-up during the postnatal period. This heightens the need for research to generate evidence about the risk factors, management and outcomes of specific medical co-morbidities during pregnancy in order to provide appropriate evidence-based multidisciplinary care across the entire pathway – pre-pregnancy, during pregnancy and delivery and postpartum.

Suarez et al. introduce the concepts of serious maternal morbidity (SMM) and near-miss maternal morbidity as more common, accessible outcomes that provide us with the opportunity to improve care pathways. They marry these thoughts with training opportunities in Latin America for care of women with acute illness in pregnancy, be it pre-existing or pregnancy-induced. The evolution of the specialty for physicians, responding to the increasing complexity and volume of medical problems encountered in pregnancy and the relationship with maternal fetal medicine and other obstetric specialists has led to different models of care but similar challenges. Contributors from the WHO, Özge Tuncalp and Vanessa Brizuela, describe the key policies and strategies that are shaping global maternal health today. The paper highlights the transition from the Millennium Development Goals (MDGs) to the SDGs, and focuses on detailing the post-2015 SDG agenda. The SDGs provide an overarching umbrella under which decades of work in maternal and newborn health come together and the authors take us through the Global Strategy for Women's, Children's and Adolescent's Health (2016–2030) which has emerged as a new roadmap for maternal health for the next 15 years.

Julia Hussein outlines the link between maternal health and NCDs at the global level. The article draws attention to the growing burden of NCDs in maternal health and ties it to the concept of obstetric transition – the shift from maternal mortality to maternal morbidity. Also, the article highlights the critical link between NCDs and the ‘life course’ perspective as the paradigm is now shifting away from a ‘siloed approach’ that regards maternity care as distinctly different from pre- and post-pregnancy maternity care and infant-pediatric care, to the broader continuum of reproductive-maternal-neonatal-child health. Finally, the article emphasises the critical role that health systems play in addressing NCDs.

Sumedha Sharma takes a global health perspective on the recent XXI International Society of Hypertension in Pregnancy (ISSHP) meeting in São Paulo, Brazil. The paper situates the meeting within the context of the Millennium Development Goals and Sustainable Development Goals. She highlights key presentations and research that focussed on global inequities in quality of care, treatment and management. The paper discusses the solutions that were offered during the meeting to bridge these inequities. Finally, the paper reflects on the role of the joint ISSHP/ISOM Global Health Committee in advancing the maternal health agenda.

Eleni Tsigas of the Pre-eclampsia Foundation (USA) describes the crucial role of patient advocacy in advancing global maternal health. Advocacy plays a critical role in ensuring that commitments translate into concrete action, and civil society groups in particular can hold governments and other stakeholders accountable to global, as well as regional and national, commitments. In this article, the author illustrate the different ways that the Pre-eclampsia Foundation has engaged pre-eclampsia survivors, practitioners, policy-makers and other takeholders in raising awareness about pre-eclampsia and advancing research. There are also two articles describing obstetric medicine training in the UK and the USA to continue our series looking at the development of obstetric medicine around the globe. Adam Morton uses two case studies to illustrate how traditional practices amongst migrant women may lead to adverse pregnancy outcomes.

The issue concludes with Sandra Lowe’s piece on The Way Forward for obstetric medicine from a global perspective, highlighting once again that both health-related (i.e. provision and access) and non-health-related strategies will be required. Health care provision and access, research, clinical and research collaboration and engagement of women and their communities, particularly through digital technology, are all discussed. There is much to be done for each of us at home and abroad.