Of the 585,000 women who die each year from pregnancy-related causes, about one in
every four dies from hemorrhaging, according to a World Health Organization (WHO)
analysis. Infection (sepsis) leads to about one of every six deaths. Other major causes
include eclampsia and other hypertension-related disorders, and obstructed labor.1 Most of these deaths are in developing countries, and most
could be prevented with access to good pregnancy-related care.
For every maternal death, hundreds more women suffer morbidities. A study coordinated
by FHI in four countries found 153 women sustained life-threatening or serious morbidities
per maternal mortality in Bangladesh, 175 in India, 297 in Egypt, and 908 in Indonesia.
Complications included hemorrhaging, convulsions, vaginal tears and prolonged fever, some
of which result in chronic debilitating conditions.2
Prevention strategies have traditionally focused on the prenatal and delivery periods,
yet a recent analysis concluded that the postpartum period is also critical. "In both
developing countries and the United States, more than 60 percent of maternal deaths
occurred in the postpartum period," reported the analysis of nine studies published
since 1985. Hemorrhage, pregnancy-induced hypertension complications, and obstetric
infection were the most common causes of postpartum death. Nearly half of the postpartum
deaths occurred within one day of delivery, and 80 percent within two weeks. Ironically,
the traditional time for the first postpartum visit by mother and baby is at six weeks, a
time when there is no longer very much danger of maternal death.3
To address this need, a WHO panel of experts on postpartum care is expected to
recommend later this year that mothers should have a postpartum checkup within three days
of delivery. "An early postpartum visit can help the mother and baby, catching fever,
sepsis, heavy bleeding, secondary postpartum hemorrhage," says Jerker Liljestrand,
chief of WHO's Maternal and Newborn Health and Safe Motherhood Programme, which
coordinated the expert panel. "The traditional postpartum visit at six weeks is not
based on science."
"We need to pay much more attention to the postpartum period," says Dr.
Judith Fortney, FHI's corporate director for scientific affairs and an expert in maternal
health. "It used to be that a public health nurse would visit the mother several days
after the delivery. But this doesn't happen anymore, in developed or developing countries.
Women are dismissed from the health center or hospital often six hours after delivery. A
lot of things can go wrong in the first few days."
It is important for family members to realize that emergency care may be necessary
after delivery, she says. "A mother can bleed to death slowly," says Dr.
Fortney. "She could have high fevers indicating an infection. Lactation might not be
well established, and the baby can become dehydrated."
Health risks
Maternal deaths and morbidities decline when women have fewer pregnancies, says Dr.
Fortney. "Family planning reduces the total number of pregnancies, so the number of
mortalities and morbidities related to pregnancy goes down," she says. "But
family planning does not make any difference in obstetric risks once a woman is pregnant.
So we also have to make pregnancy safer. To do that, we need to focus on improving access
to good quality obstetric care."
Increased use of contraceptives can affect the maternal mortality rate, which measures
maternal deaths per 100,000 women ages 15 to 49. However, family planning does not affect
the ratio of maternal deaths per live births, since this figure only considers women who
are pregnant. Hence, most studies of intervention efforts use a decline in the maternal
mortality ratio as an indication of success. In developing countries, about 480 women die
for each 100,000 live births, a ratio almost 18 times higher than in developed countries.
Africa, which has only 20 percent of the world's births, accounts for about 40 percent of
all maternal deaths.4
Health risks due to pregnancy are greater for adolescents (under age 16) and older
women (over age 40). The risks are also greater during a woman's first pregnancy. Any
woman, however, can have sudden, unpredictable complications during delivery. Hence, all
women need prompt access to good obstetric care, not just women at high risk. A well-known
study in Bangladesh found that 43 percent of all maternal deaths were among women in their
20s, the age group with the greatest number of births but the lowest relative risk.5
"The greatest number of maternal deaths actually occur in women who are
'low-risk,'" explained Deborah Maine of Columbia University and her colleagues in a
recent analysis of reproductive health data. "Even though we may not be able to
predict or prevent most obstetric complications, we certainly know how to treat
them."6
By 1950, most obstetric complications had become manageable in developed countries with
the introduction of improved obstetric surgical procedures, better aseptic techniques,
antibiotics, the drug oxytocin (which contracts the uterus and reduces bleeding), blood
transfusions and banks, and management of eclampsia (convulsions). Although most of these
steps can be taken in resource-poor settings, quality obstetric care is still not
available to most women in developing countries.
Improvements in care are not always expensive. A regional hospital in rural Tanzania
found that low-cost interventions resulted in a sharp decline in the maternal deaths at
the hospital. The number of maternal deaths declined from 28 in 1984 to eight in 1991,
even as the number of annual deliveries increased from about 3,000 to nearly 4,300. Many
of the 22 specific interventions involved motivating the staff to pay closer attention to
problems and providing them with the support needed to meet emergencies.
At monthly meetings, coordinators informed staff about events of the previous month and
solicited ideas from all technical levels, including ward attendants and nursing
assistants. Training activities helped maintain skills, including proper attention to
sterilization and disinfection of equipment. Better management routines in cases of severe
anemia were introduced. Complaints about patient management were addressed. All essential
staff received housing within the hospital compound, allowing them to be readily
accessible for an emergency. Drug supplies were better organized, including a small
storage for unforeseen shortages.
"While widespread poverty remained constant or increased, ear-marked interventions
in specific areas tended to improve morale and attitudes among staff, in spite of the
limited resources," reports Dr. Godfrey Mbaruku, who led the study.7
Another study analyzed how a community-based intervention using midwives affects
maternal mortality. For three years in the Matlab area of Bangladesh, trained midwives
worked with community health workers and traditional birth attendants to monitor and
address pregnancy and delivery complications. The midwives were expected to assist with
antenatal care, attend as many home deliveries as possible, detect and manage obstetric
complications, and accompany patients requiring referral for higher-level care to the
project central maternity clinic. A comparison group of villages, which had a similar
maternal mortality ratio during the three years prior to the intervention, did not have
these midwives. During the three-year intervention, the maternal mortality ratio was 63
percent lower in the area with midwives, 140 deaths per 100,000 live births compared to
380 in the control area.
"Maternal survival can be improved by the posting of midwives at the village
level, if they are given proper training, means, supervision and back-up," the study
concluded, emphasizing the importance of an "effective referral system." It also
pointed out that more work needs to be done to determine if this type of project can be
sustained and replicated on a large scale.8 A subsequent study
of this Matlab intervention found that other factors were as important as the use of
midwives, such as the availability of cesarean sections and blood transfusions at the
local hospital.9
Ten projects in West Africa, coordinated through Columbia University as the Prevention
of Maternal Mortality (PMM) Network, have focused for nearly a decade on various
interventions. When a woman has an obstetric complication, her survival may be decided by
how long it takes for her to receive adequate emergency care. The PMM project identifies
three crucial delays: in deciding to seek obstetric care, in reaching an obstetric care
facility, and in actually receiving care after arrival.
PMM emphasizes making sure that obstetric care facilities are capable of providing good
care, which could reduce the third level of delay. "It is illogical (perhaps even
unethical) to encourage people to seek treatment for problems related to pregnancy until
you have made sure that the obstetric services are functioning properly," explains a
PMM report.10
Improvements in emergency obstetric care included restoring inadequate surgical
theaters to working order, developing blood banks, developing a revolving fund for drugs,
improving record-keeping, and training resident physicians, nurses and midwives. The team
at a district hospital in Sierra Leone, for example, reported that the number of women
seeking treatment for obstetric complications increased from 31 in 1990 to 157 in 1995
after such improvements, while the "case fatality rate" (the number of deaths
among all women treated) dropped sharply, from nearly one of every three in 1990 to one of
every 20 in 1995. Cesarean sections increased from two in 1990 to 38 in 1995, indicating
the hospital's capability of performing the procedure when necessary had increased
substantially.11
PMM projects also focused on the other two delays -- when the decision is made to seek
emergency obstetric care and how long it takes for a woman to reach the facility. To
address delays in reaching emergency care, projects helped develop better transportation
and communication systems. Community information and education efforts encouraged families
to seek emergency services, the remaining time-frame of delay.
TBA training
A growing sentiment exists among international experts that training traditional birth
attendants (TBAs) may not be worth the resources. Since TBAs deliver babies in remote
villages, training TBAs to wash their hands, use a new razor to cut the umbilical cord and
take other steps could theoretically prevent infection at delivery. They could also learn
to reduce hemorrhaging by such simple techniques as putting the baby immediately to the
breast and massaging the mother's belly. Nipple stimulation and massage tend to contract
the uterus, activating the natural oxytocin in the body, and thus reducing bleeding.
A recent study in Ghana, however, found no statistical difference in eight of 10
indicators for whether TBA training resulted in better health for mothers. Conducted by
FHI with the Ghana Ministry of Health, it was the first study to examine whether TBA
training was a factor in dealing with such problems as retained placenta, postpartum
fever, foul discharge and excessive bleeding. With a retained placenta or postpartum
fever, training seemed to help, but only slightly. "Most of the time, training did
not make a difference," explains Dr. Jason Smith of FHI, who coordinated the study.
The study interviewed 1,961 women in two districts who had contact with a TBA during
pregnancy, delivery or in the postpartum period. The districts, one with good access to
emergency care and one without, had both trained and untrained TBAs.
At a recent international meeting sponsored by the United Nations Children's Fund
(UNICEF), where Dr. Fortney presented the findings on TBA training in Ghana, experts
discussed whether to continue to invest resources in TBA training. While no decision has
yet been made to discontinue TBA training, UNICEF has begun to lower its expectations of
TBA training.
Another area traditionally assumed to make a difference in maternal mortality is good
prenatal care. A WHO report summarizing the current research concludes that prenatal care
has a more limited role to play in preventing maternal mortality or morbidity than
conventional wisdom suggests.12
"We have a much clearer idea than we did have," says Carla AbouZahr of WHO's
Safe Motherhood Programme. "The prenatal period is an excellent time for syphilis
screening and treatment, to give tetanus toxoid immunization, and to give iron
supplements, which benefit the mother and baby. Other diseases can also be treated that
can aggravate pregnancy such as malaria, tuberculosis, worm infestation. Also, prenatal
care is an opportunity to put the woman and family in contact with the healthcare service
and inform them of possible complications, so that if a difficulty arises in delivery, it
is recognized in time and people know where to go for care." This can be especially
important for women under age 16 or older women.
Research has not reached conclusions on other issues, however. Scientists are not sure
how well monitoring blood pressure during pregnancy can affect pre-eclampsia, for example,
says AbouZahr. "The convulsions may happen anyway, with no warning signs."
Measuring progress
UNICEF and WHO have developed new indicators that can determine more precisely which
types of interventions are needed and whether they are successful. These
"process" indicators are targeted to specific programmatic steps, in contrast to
the main "outcome" indicators, such as the maternal mortality ratio, or the
number of deaths.
There are six primary process indicators: the availability of emergency obstetric care,
the geographic distribution of these facilities, proportion of births in medical
facilities, proportion of women with complications who are treated at medical facilities,
percentage of all births done by cesarean sections, and the case fatality rate. Each of
the indicators has acceptable levels defined.
For example, the indicators say there should be at least four basic emergency obstetric
care facilities and one comprehensive facility for every 500,000 people. A basic facility
should be able to administer antibiotics; oxytocic drugs and anticonvulsants by injection
or intravenously; perform manual removal of the placenta and manual vacuum aspiration of
retained placenta material; and perform an assisted vaginal delivery. A comprehensive
facility should be able to perform these functions, as well as cesarean sections and blood
transfusions.
In Morocco, the indicator concerning number of facilities was important, explains
Maine, who has worked with maternal mortality intervention projects in Africa for the last
decade. "We found there was only one facility that was performing cesarean sections
and giving blood transfusions in an area around Fès, a large city, where there should
have been four," she says. "Morocco officials had been focusing on antenatal
care and normal deliveries rather than making enough emergency obstetric care facilities
available."
Other guideposts for the indicators are 15 percent of all births taking place in an
emergency obstetric care facility, 5 to 15 percent of all births being cesarean sections,
and a less than 1 percent case fatality rate among women with obstetric complications in
emergency facilities.
A UNICEF study in India examined maternal mortality using these new indicators. By
focusing on these process indicators rather than the outcome maternal mortality ratio, it
was able to identify more specific steps that programs could take. For example, it found
few cesarean sections and high case fatality rates, suggesting better emergency care was
needed. It also found very low numbers of complications reaching the facilities, which
"point to the need for encouraging families to use them."13
For program management purposes, these indicators are essential, says AbouZahr of WHO.
However, no one indicator should be viewed in isolation, she cautions, nor should they be
used as targets. For example, if focusing only on the case fatality rate, she says, a
hospital might reduce the rate by simply turning away the more difficult cases. When
considering interventions, one strategy must always be monitored, and improved upon, she
says: "We all agree now on the critical importance of timely access to obstetric
care."
-- William R. Finger
References
- World Health Organization. Mother-Baby Package:
Implementing Safe Motherhood in Countries. (Geneva: World Health Organization Division
of Family Health, 1994) 1-2.
- Fortney JA, Smith JB. The Base of the Iceberg:
Prevalence and Perceptions of Maternal Morbidity in Four Developing Countries. (Research
Triangle Park, NC: Family Health International, 1997) 98-99.
- Li XF, Fortney JA, Kotelchuck M, et al. The postpartum
period: the key to maternal mortality. Int J Gynecol Obstet 1996;54(1):1-10.
- World Health Organization. Maternal mortality -- worse
than we thought. Safe Motherhood 1995; Issue 19:1-2.
- Chen LC, Geshe MC, Ahmed S, et al. Maternal mortality in
rural Bangladesh. Stud Fam Plann 1974;5(11):337.
- Maine D, Freedman L, Shaheed F, et al. Risk,
reproduction and rights: the uses of reproductive health data. In Population and
Development: Old Debates, New Conclusions. Ed., Cassen R. (New Brunswick: Transaction
Publishers, 1994) 212.
- Mbaruku G, Bergström S. Reducing maternal mortality in
Kigoma, Tanzania. Health Policy Plan 1995;10(1):71-78.
- Fauveau V, Stewart K, Khan SA, et al. Effect on
mortality of community-based maternity-care programme in rural Bangladesh. The Lancet 1991;338(8776):1183-86.
- Maine D, Akalin MZ, Chakraborty J, et al. Why did
maternal mortality decline in Matlab? Stud Fam Plann 1996;27(4):179-87.
- Center for Population and Family Health. Abstracts
from the PMM Results Conference: June 19-21, 1996, Accra, Ghana. (New York: Columbia
University, 1996) 9-10.
- Center, 19.
- Rooney C. Antenatal Care and Maternal Health: How
Effective Is It? A Review of the Evidence. Geneva: World Health Organization, Division
of Family Health, 1992.
- Nirupam S, Yuster EA. Emergency obstetric care:
measuring availability and monitoring progress. Int J Gynecol Obstet 1995;50 Suppl
2:S79-88.
For more information, visit Family Health International's Website at www.fhi.org
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