Every minute of every day, somewhere in the world, a woman dies as a result of complications arising during pregnancy and childbirth. The ma- jority of these deaths are avoidable. [4]
Since 1982, the World Health Organization (WHO) has systematically reviewed indexed med- ical literature, nonindexed publications, and reports from national and local authorities regarding ma- ternal mortality and maternity care coverage world- wide. Its best estimate in 1987 was that there were in excess of 500,000 pregnancy-related deaths per
Every minute around the world 380 women become pregnant
190 women face unplanned or unwanted preg- nancies
110 women experience pregnancy-related com- plications
40 women have unsafe abortions 1 woman dies
White Ribbon Alliance for Safe Motherhood. Awareness, Mobilization, and Action for Safe Motherhood: A Field Guide.
Washington, DC: NGO Networks for Health, 2000.
year, most of them preventable [4]. Subsequent re- analysis of the data revealed that closer to 585,000 women die per year [5]. Of these nearly 600,000 deaths, more than half come from just eight coun- tries: Bangladesh, Ethiopia, India, Indonesia, Nepal, Nigeria, Pakistan, and Uganda. Nepal suf- fers a maternal death every five minutes, Nigeria every ten minutes.
The worldwide Safe Motherhood Initiative was launched in 1987 in Nairobi, Kenya. The goal of this meeting was to raise awareness, alert the inter- national community to this silent tragedy, and mo- bilize efforts and resources on the behalf of women.
At the 1990 World Summit for Children, 166 na- tions signed on to the action plan goals, one of which was to reduce maternal mortality by 50 per- cent by the year 2000 [6]. In September 2000, the United Nations member states adopted the Millennium Development Declaration that rein- forced the emphasis on healthy women and safe pregnancies and birth for development in any coun- try. The Millennium Development goals included the reduction of maternal mortality by 75 percent between 1990 and 2015, using the proportion of births attended by skilled personnel as an indicator for this goal [7].
Mortality figures, though difficult to obtain, have been the most sensitive indicator of the health of women. However, in considering maternal mor- tality, it is important that a far wider scope of preg- nancy-related health problems, including maternal trauma, chronic disease, and reduced energy out- put, which have profound ramifications for the family and the economy, not be overlooked.
Maternal mortality represents only the tip of the mountain of health problems for women. The road to maternal death and disability for many women begins at birth, when they are born female.
Morbidity has been even more difficult to define and measure. Many women never enter the health care system during pregnancy, even when gravely ill, and therefore their deaths or disabilities are not captured in vital statistics or other records.
A myriad of service factors—from improper care to a lack of supplies, transport to a referral center, surgical capability, blood banks, and money with which to access available care—contribute to maternal mortality in developing countries. These factors most recently have been categorized as the
“enabling environment or system of care” as dis- tinct from the person who provides needed care [8].
Cultural factors that limit access to care tend to be less well known and less well documented.
Utilization of faith healers, local herbs, over-the- counter treatments, and “quack” practitioners who claim unearned health credentials can complicate access to appropriate care given in a timely fashion.
When disease is believed to be caused by black magic or lack of faith, orthodox medical services based on belief in the germ theory are not seen as offering solutions. Cultural factors also include the existing norms that define the status of women, with the consequence of interfering with a woman’s decisions to seek care in a timely manner.
To confront the problems of maternal mortality and morbidity, issues of quality and access must be addressed. They can be analyzed within the frame- work of the three delays [9]:
1.Delay in recognition that there is a problem 2.Delay in reaching the appropriate level of care
once the problem/complication has been recog- nized
3.Delay in receiving the appropriate care after ar- rival at the service site
Maternal Death
The World Health Organization defines maternal mortalityas follows:
Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by the pregnancy it- self or its management, but not from accidental or incidental causes [10]. Accidental or incidental causes are those that would have caused death irre- spective of pregnancy, such as traffic accidents, gunshot wounds, poisonings, and so forth.
Deaths are then divided into two categories:
1.Direct obstetrical deaths, resulting from obstet- rical complications of the pregnancy state (pregnancy, labor, and puerperium), from inter- ventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above [10].
2.Indirect obstetrical deaths, resulting from pre- vious existing disease or disease that developed during pregnancy, and that were not due to di- rect causes, but were aggravated by physiologic effects of pregnancy [10].
In developing countries, the five major direct causes of maternal death are (1) hemorrhage, (2) sepsis, (3) pregnancy induced hypertension, (4) un- safe abortion, and (5) obstructed labor.
Ways to Express Mortality
There are three main ways to calculate and express maternal mortality: (1) rate, (2) ratio, and (3) life- time risk.
Maternal Mortality Rate The maternal mortality rate is expressed as the number of women who die while pregnant or within the first 42 days after pregnancy, from any cause related to or aggravated by preg- The patient was a 32-year-old Gravida 3, one live baby, who had been attendant since 12 weeks of pregnancy. She was my friend and came from this very village. The patient came in with labor pains at 9 p.m. onset 4 p.m. P.V. [vaginal examination] done.
Os was 2 cms. dilated. Membranes intact. Labor progressed well. Patient delivered spontaneously a live female infant at 4:15 a.m. The placenta appeared to be complete but the membranes was ragged.
Patient started bleeding. IV 500 cc set up with pitocin. External bimanual compression done with- out effect. Manual removal [uterine exploration]
done. Only blood clots expelled. Internal bimanual compression done without effect. Another IV 1000 mls set up and the patient was transferred. There were transportation difficulties and the road is very bad. It took us 4 hours 10 minutes to travel a 35 km journey. The patient received 2500 mls of IV fluids but very unfortunately the IV got infiltrated on the way; but due to the bad road I could not get the vein.
All attempt to start the IV again failed. The patient expired at the hospital before the Doctor arrived.
EBL 2500cc. I collapsed at the hospital. They gave me Valium 20 mgs and put me in a bed. I was not aware for some time. I cried and felt very bad. They talked to me and explained that they sometimes have such women die at their hospital with everything. I did not feel confident and competent. Sometimes when I think about it now I cry.
This rural midwife trained in Life-Saving Skills had organized the TBAs in the seven villages around her to come to her maternity home for continuing edu- cation and to refer their patients with problems.
Note that once the bad road was graded, travel time was decreased from 4 hours 10 minutes to under an hour and a half.
Source:Marshall, M. A. Ghana Registered Midwives Association Continuing Education Project—Carnegie Corporation Grant B 5071, Final Evaluation Report. Unpublished evaluation of Life- Saving Skills Training Project, 1992.
nancy per 100,000 women of reproductive age in a given year [10]. The WHO International Classification of Diseases (Vol. 10, 1997) has re- vised the definition to include deaths within one full year after the termination of pregnancy. Because this definition is less in use and difficult to obtain, it is important to see how data are reported when making comparisons over time or from one country to another for both maternal mortality rate and ratio [11]. The rate is determined as follows:
The advantage of using the maternal mortality rate is that it compares maternal deaths with all women at risk in the population. In a society with a reliable system of gathering statistics, this provides a clear way of expressing deaths. However, in most developing countries, the census data are too old or faulty to make it possible to use rates.
Maternal Mortality Ratio The maternal mortality ratio is expressed as the number of women who die while pregnant or within the first 42 days after pregnancy, from any cause related to or aggravated by preg- nancy per 100,000 live births in a given year [10].
The advantage of using maternal mortality ratio is that the numbers of live births are compar- atively easier to count. This is the most commonly used way to express trends within a country and to make cross-country comparisons.
Lifetime Risk of a Maternal Death The lifetime risk of a maternal death is calculated by multiplying the maternal mortality rate by 30 (the number of years of exposure between ages 15 and 44), but the effec- tive duration of exposure can vary widely. The life- time risk of maternal death can be more simply stated as the risk of an individual woman dying from pregnancy or childbirth during her lifetime.
Calculations are based on maternal mortality and fertility rates in the country. A lifetime risk of 1 in 3000 represents a low risk of dying from pregnancy and childbirth, while 1 in 100 is a high risk [12].
Table 4-1 presents regional data on lifetime risk of a woman dying during the childbearing cycle.
The advantage of using lifetime risk of dying a maternal death is that it recognizes that women of high fertility or women lacking in universal access
Number of maternal deaths in a year 100,000 live births in a year Number of maternal deaths in a year 100,000 women of reproductive age in the population
to effective family planning have an extremely high risk of dying as a result of pregnancy or childbirth.
Maternal Morbidity
As difficult as it is to obtain accurate maternal mor- tality data, morbidity data collection is far more difficult. However, women worldwide are dying during pregnancy of diseases for which we have prevention and treatment strategies. In Nigeria, where a maternal death occurs every ten minutes, 10 percent of maternal deaths are from malaria.
Other common causes include maternal tetanus, tu- berculosis, and increasingly HIV/AIDS.
One of the huge challenges for this century is improved prevention, recognition, and low-technol- ogy treatment for morbid conditions of pregnancy.
Currently, there is no global agreement as to defini- tions of pregnancy-induced hypertension, ob- structed labor, and hemorrhage. Definitions are crucial because they dictate what treatment proto- col will be used. A practical example of this is hem- orrhage, which is defined as 500 cc of blood loss during the birth process. A woman entering labor with a hemoglobin of 12 g can tolerate this blood loss with few symptoms. A woman entering labor with a hemoglobin of 4 g may well go into shock and die with a 300 cc blood loss.
Historically, much time and effort have been in- vested in the training of traditional birth attendants (TBAs), feeling that this investment would decrease maternal deaths in the community. More than 20 years experience has shown that this has not con- tributed significantly to a reduction in mortality.
Clearly, it is unreasonable to expect that community women, no matter how skilled and loving, can affect great change when working within a system bedeviled with poor transportation, lack of emergency funds, inadequate blood safety, and poor referral institu- tions. Rendering maternity care is a system problem
Women’s Lifetime Risk by Region TABLE 4-1
Region Lifetime Risk of Dying
Africa 1 in 16
Asia 1 in 65
Latin America/Caribbean 1 in 130 All developing countries 1 in 48 All developed countries 1 in 1800
Source:From 1997 World Health Organization data, in Ross, S. R.
Promoting Quality Maternal and Newborn Care: A Reference Manual for Program Managers. Washington, DC, Cooperative for Assistance and Relief Everywhere (CARE), 1998, pp. 1, 17.
requiring multiple levels of preparedness and active community awareness and participation.
Many nations have felt that moving childbirth into institutions was the answer to maternal mor- tality. Experience has shown that site of delivery is not the critical factor. The linchpin of improved ma- ternal outcomes is introducing skilled providers at every level of care. An important distinction has evolved to differentiate between a trained and a skilledprovider. A trained provider may have as lit- tle as a five-day training for TBAs and is not in a position to negotiate and handle emergencies.
Persons who are skilled providers are referred to as those who have midwifery skills, whether or
Skilled Provider A skilled provider refers exclusively to a person with midwifery skills (for example, a doctor, midwife, or nurse) who has completed a set course of study and can manage normal labor and delivery, recognize the onset of maternal and neona- tal complications, perform essential Life-Saving Skills, initiate treatment, and supervise the referral to a higher health care facility.
Source:Family Care International. Saving Lives: Skilled Attendance at Childbirth. New York: FCI, in collaboration with Safe Motherhood Inter-Agency Group, 2001, pp. 5–16.
not they are midwives. At the ten-year anniversary conference in Sri Lanka for the Safe Motherhood Initiative, it was noted that worldwide 75 million births take place annually and 60 million of those births take place without the presence of a skilled attendant.
The single most critical intervention is to ensure that a health worker with midwifery skills is pres- ent at every birth, and transportation is available in case of emergency. A sufficient number of health workers must be trained and provided with essen- tial supplies and equipment especially in poor and rural communities. [13]
Clearly the presence of a skilled provider, though essential, is not sufficient to save women’s lives. Providers work within teams with comple- mentary skills and need essential equipment and supplies. Given a supportive environment, skilled providers may render safe, high-quality care in any site: home, maternity home, birth center, health post, district hospital, or referral hospital.
The inputs at each level of care play an important role in rendering emergency obstetrical services when required. The levels of obstetric care and personnel providing such care are summarized in Table 4-2.
Levels of Obstetric Care TABLE 4-2
Comprehensive Emergency Obstetric Care Facilities: 1 per 500,000 people District Hospital Providers
Perform surgery under general anesthesia Physicians, midwives,
Perform assisted removal (e.g., D&C) of retained placental pieces paramedical and support
Perform manual removal of retained placenta staff
Perform assisted vaginal delivery (e.g., vacuum extraction or forceps delivery) Provide safe blood replacement
Administer parenteral (IV or IM) antibiotics Administer parenteral (IV or IM) sedatives Administer parenteral (IV or IM) oxytocics
Basic Emergency Obstetric Care Facilities: 4 per 500,000 people Health Center
Perform manual removal of retained placenta/pieces Physicians and/or midwives, Perform assisted vaginal delivery (e.g., vacuum extraction) paramedical and support Administer antibiotics, sedatives (e.g., Valium, magnesium sulfate), and oxytocics staff
(ergometrine, Pitocin) IM or IV, and IV fluids.
Obstetric First Aid in the Community Village/Community Level
Uterine massage/pressure point Junior health staff,
May be able to administer sublingual/nasal/IM oxytocics (ergometrine) traditional birth attendants,
Provide oral rehydration salts local leaders, women’s
groups, community workers, families
Source:Ross, S. R. Promoting Quality Maternal and Newborn Care: A Reference Manual for Program Managers. Washington, DC: Cooperative for Assistance and Relief Everywhere (CARE), 1998, p. 5.55.