Editorial
Centring the invisible mother
BSIP/UIG/Getty Images
For the CDC report on maternal
mortality see https://www.cdc.
gov/vitalsigns/maternal-deaths/
For WHO data on maternal
mortality see http://
gamapserver.who.int/gho/
interactive_charts/mdg5_mm/
atlas.html
For more on block grant funding
for child and maternal health
see https://www.propublica.org/
article/die-in-childbirth-maternal-
death-rate-health-care-system
Irakli Abashidze/EyeEm/Getty Images
For the statement from WHO
see https://www.who.int/news-
room/detail/14-03-2019-who-
urges-governments-to-enforce-
bans-on-tobacco-advertising-
promotion-and-sponsorship-
including-in-motor-sport
For more on Philip Morris
International’s Mission Winnow
see https://www.tobaccotactics.
org/index.php?title=Motorsport_
Sponsorship
2010 www.thelancet.com Vol 393 May 18, 2019
The USA had an average pregnancy-related mortality
(PRM) of 17·2 per 100 000 livebirths between 2011–15,
according to a report from the US Centers for Disease
Control and Prevention (CDC). Released May 7, the
report found that approximately 700 women in the USA
die each year because of pregnancy-related conditions,
and 60% of maternal deaths were preventable if “one or
more reasonable changes” had occurred. Causes of death
varied by time prepartum and postpartum, but the most
common were cardiovascular conditions.
The study drew on the CDC’s Pregnancy Mortality
Surveillance System and state data. In 1987, the CDC
reported an initial national PRM of 7·2, which has risen
steadily nearly every year since. Factors that contribute
to maternal mortality range from patient issues, such
as poor knowledge of warning signs, to larger, more
systemic issues that could affect maternal health: lack
of transportation access, inadequate care, and lack of
obstetric emergency knowledge from care providers.
All of these factors highlight a lack of attention to the
Smoke and mirrors: new tobacco products and Formula 1
Clear links between Formula 1 and smoking were right-
ly confined to history decades ago. However, it now
appears that connections are developing once more.
British American Tobacco (BAT) joined with McLaren
in February to advertise several products including a
so-called heat-not-burn, tobacco-containing device—a
hybrid of the e-cigarette and the traditional cigarette.
Under the branding “A Better Tomorrow”, the union is
about “transforming [the] tobacco agenda, at the heart
of our portfolio of potentially reduced risk products”,
BAT told The Lancet on May 8.
Philip Morris International, known for Marlboro
cigarettes, is not advertising their heated tobacco device—
IQOS—directly with Formula 1, but on Oct 3, 2018, they
launched Mission Winnow, a project that indirectly links
their tobacco products to Ferrari’s F1 team.
WHO rightly condemned both campaigns on March 14,
prior to the Australian Grand Prix, urging countries to
enforce bans on tobacco advertising, promotion, and
sponsorship at all sporting events under the 2003 WHO
Framework Convention on Tobacco Control. Philip Morris
health of mothers before, during, and after they give
birth—only 6% of state and federal funding for child and
maternal health in the USA focuses on the mother.
The USA has the highest maternal mortality in the
developed world, which worsens in light of stark racial
disparities. African-American women have a pregnancy-
related mortality of 42·8 per 100  000 livebirths,
three times that of white women, ranking between
Turkmenistan and Brazil. At 13 PRM, even white women
in the USA rank behind Saudi Arabia and Kazakhstan. That
one of the world’s richest countries, with the highest per
capita health-care spending globally, has backslid so far is
a shocking development. The image of maternal death we
see in the media is often a woman in labour being wheeled
into the delivery room and a slow fade to black. But the
vast majority of deaths (82%) occur before or after the day
of delivery. The USA needs to recommit to ensuring health-
care providers centre the needs and health of mothers—of
all races—not just on the day of birth, but throughout the
entirety of their pregnancy and beyond. n The Lancet
and BAT then removed their controversial brandings for
the Australian race, but they returned to adorn cars and
drivers at subsequent F1 contests in Bahrain, Shanghai,
and Azerbaijan. At the Spanish Grand Prix last weekend,
only Mission Winnow appeared on cars and clothes of
Ferrari drivers Charles Leclerc and Sebastian Vettel.
Philip Morris’s promotion of its heat-not-burn product
was given a further boost after the US Food and Drug
Administration authorised the marketing of IQOS on
April 30. The device, whose name derives from the
phrase “I quit original smoking”, is one of several heat-
not-burn gadgets now on sale in numerous countries
across the globe.
Allowing unrestricted use of e-cigarettes and vaping
devices as adjuncts in tobacco smoking cessation
in many countries was reckless, to say the least. But
permitting the sale and promotion of heat-not-burn
tobacco devices, without any clear evidence of safety
seems irresponsible in the extreme. As a first step, any
form of promotion—both covert and transparent—
should be prohibited worldwide. n The Lancet