The untold story: how the health care systems in developing countries contribute to maternal mortality

This article attempts to put together evidence from maternal mortality studies in developing countries of how an inadequate health care system characterized by misplaced priorities contributes to high maternal mortality rates. Inaccessibility of essential health information to the women most affected, and the physical as well as economic and sociocultural distance separating health services from the vast majority of women, are only part of the problem. Even when the woman reaches a health facility, there are a number of obstacles to her receiving adequate and appropriate care. These are a result of failures in the health services delivery system: the lack of minimal life-saving equipment at the first referral level; the lack of equipment, personnel, and know-how even in referral hospitals; and worst of all, faulty patient management. Prevention of maternal deaths requires fundamental changes not only in resource allocation, but in the very structures of health services delivery. These will have to be fought for as part of a wider struggle for equity and social justice.

Retrospective maternal mortality case ascertainment in West Virginia, 1985 to 1989

OBJECTIVE

The death of women from pregnancy-related causes remains a threat to national maternal and child health. Maternal deaths as persistent, albeit rare occurrences are overlooked if vital registration systems are relied on to report such deaths.

STUDY DESIGN

Live birth records were matched with death records for women of reproductive age to detect if a woman died within 1 year of delivery. The data for potential cases were reviewed by committee and classified as maternal and nonmaternal deaths.

RESULTS

Of all linked birth-death records, 32% were related to pregnancy: 81% were directly related to pregnancy and 19% were indirectly related to pregnancy. The most frequent causes of death were hemorrhage and embolism. Thirty-eight percent of the women were transferred to tertiary hospitals before death. The case ascertainment through this study improved maternal death detection by 100% over official vital statistics.

CONCLUSION

Enhanced maternal mortality surveillance increased the detection of maternal death in West Virginia. Case review of these deaths yielded important information useful in shaping the state's perinatal system.

Maternal mortality associated with hypertensive disorders of pregnancy in Africa, Asia, Latin America and the Caribbean

OBJECTIVE

To present estimates of maternal mortality associated with hypertensive disorders of pregnancy in Africa, Asia, Latin America and the Caribbean, and to discuss strategies to prevent these deaths.

DESIGN

Retrospective review of all available data.

SETTING

Database of the World Health Organization's Maternal Health and Safe Motherhood Programme.

MAIN OUTCOME MEASURES

Estimates of the total maternal mortality and the proportions of deaths associated with hypertensive disorders of pregnancy.

RESULTS

Estimates of mortality associated with hypertensive disorders of pregnancy were similar in Africa, Latin America and the Caribbean, despite considerably higher total mortality in Africa. Variations in both overall mortality and that associated with hypertensive disorders of pregnancy were greatest in Asia. Despite their limitations, these data suggest that between 10-15% of maternal deaths are associated with hypertensive disorders of pregnancy, and that 10% are associated with eclampsia.

CONCLUSIONS

Where maternal mortality is relatively high, the excess is likely to be due to a high mortality associated with haemorrhage and infection and reductions are most likely to come from reductions in these deaths. Evidence from both developed and developing countries suggests that deaths associated with hypertensive disorders of pregnancy are the most difficult to prevent. More rigorous assessment of interventions designed to prevent these deaths is urgently required.

Family planning needed for all women

Dr. Angele Petros-Barvazian, Director of the WHO's Family Health Division in Geneva, outlined a strategy for the survival of mothers during the FIGO congress, at a plenary session on Maternal Mortality and Safe Motherhood. Of the estimated 500,000 women who die each year from causes related to pregnancy and childbirth, 99% are from developing countries, she said. The main causes of maternal mortality are postpartum hemorrhage and unsafe abortions, which go untreated because of a lack of obstetric services. But the underlying reasons for poor reproductive health are rooted in social and economic factors which affect women from childhood on, she explained. Teenage pregnancy, which carries a higher risk of mortality for both mother and child, is far more common in developing countries than in the industrialized nations. The rate in Japan is just 2%, compared with 56% in Malawi. If the age of pregnancy and marriage were delayed through family planning, this would not only save lives, but would also allow girls more time for education. Since family size falls in line with the rise in mothers' standards of education, improved education would contribute to population goals and enable women to play a more productive role in society. We see no contradiction between reproduction and a productive social role. Other important factors affecting women's reproductive health are nutrition and maternal care, she told the meeting. The populations where women's nutritional requirements are not met during pregnancy and lactation, this is frequently reflected in a high proportion of low birth weight babies. Maternal care also has a major effect on maternal mortality. Dr. Petros-Barvazian quoted the example of a small US community in which healthy women refuse all maternity care on religious grounds, and which consequently has maternal mortality rates almost as high as among unhealthy women in developing countries. Summing up, she said that the WHO strategy for the survival of mothers requires social equity and improved education for all women. For women of reproductive age, what we need is improved reproductive health and in particular, family planning for all. For pregnant women, we need improved prenatal and maternity care for all, with facilities for obstetric care for high-risk cases. Socially, we need to ensure that social and cultural relations are supportive to women in their roles as mothers to children, and not just as pregnant women. If we improve the social status of women, we will improve mortality and fertility; and the reverse is also true.

Investigating induced abortion in developing countries: methods and problems

Interest in abortion research is reemerging, partly as a result of political changes and partly due to evidence of the contribution of induced abortion to maternal mortality in developing countries. Information is lacking on all aspects of induced abortion, particularly methodological issues. This article reviews the methodological dilemmas encountered in previous studies, which provide useful lessons for future research on induced abortion and its complications, including related deaths. Adverse health outcomes of induced abortion are emphasized, because these are largely avoidable with access to safe abortion services. The main sources of information are examined, and their relevance for assessing rates of induced abortion, complications, and mortality is addressed. Two of the major topics are the problems of identifying cases of induced abortion, abortion complications, and related deaths, and the difficulties of selecting a valid and representative sample of women having the outcome of interest, with an appropriate comparison group. The article concludes with a discussion of approaches for improving the accuracy, completeness, and representativeness of information on induced abortion. Although the prospects for high-quality information seem daunting, it is essential that methodological advances accompany program efforts to alleviate this important public health problem.

Illegal induced abortion: a study of 74 cases in Ile-Ife, Nigeria

Seventy-four women with complications of induced abortion were studied prospectively at the Obafemi Awolowo University, Nigeria. Twenty of the women were interviewed privately to elicit confidential information and also to determine their attitudes to contraception and to the Nigerian national abortion law. The results showed that abortion is prevalent in all classes of women and in married as well as unmarried women. There were 13 maternal deaths, accounting for 35% of the maternal mortality in the hospital during the period. Sepsis was the most common cause of death, and most of the abortions complicated by sepsis had been performed by medical practitioners. Interviews with the women revealed that most of them had knowledge of contraception but were unwilling to use it because of wrong information. Most women did not know that abortion is illegal in Nigeria, but felt that it should be. Measures that could be of value in reducing abortion-associated maternal mortality in Nigeria include training and retraining of physicians in the management of abortion and of abortion complications, family planning education of all fertile women, provision of confidential family planning services and liberalization of the abortion law.

Birth spacing and child mortality in a Caribbean population

Ten independent variables were used to predict death before the first birthday for 4411 births that took place from 1878 to 1976 to 978 women of native ancestry on the island of St. Barthélemy. Significant predictors of death include the death of the mother within a year, the birth year, multiple birth, whether the preceding child also died before 1 year of age, and whether the next child was conceived before the index child was 1 year old. Unlike most prior studies, birth-spacing variables were only weakly related to death in the first year. The relative absence of contraceptive techniques to control birth spacing in the study population and the use of vital records rather than survey data distinguish this project from others and may account at least partly for the unusual findings.

Shanghai needs to improve its perinatal care

In view of the situation that the perinatal mortality rate of Shanghai keeps dropping, doctor Hua Jiazeng from the Shanghai No. 1 Maternity Hospital told the reporter recently that to further lower down the perinatal mortality rate in Shanghai, the perinatal care should be improved through replacing maternity facilities and equipments, keeping the mother and her baby together in the same ward in hospital, and raising the breastfeeding rate. According to the latest statistics, the maternity mortality rate is now 23.8/100.000 in Shanghai, and the perinatal mortality rate has been 12-13/1000 in the past 10 years. These numbers show that there is still a gap between Shanghai and some developed countries regarding perinatal care. There are 3 reasons behind this: 1) since the early 1980s, Shanghai has been in the birth peak period and each year there are 180,000 babies born on the average, as a result, short of beds and lack of staff, the quality of puerperium monitoring and parturition treatment is impaired; 2) maternity facilities and equipments in quite a few hospitals are obsolete and do not suit the needs of modern maternity care anymore, and many hospitals still put newly-born babies together in a big ward which make babies easy to be infected; and 3) breastfeeding rate is dropping as more families do not choose breastfeeding. Doctor Hua suggests: first, we should make a good use of the 3-level maternal and childcare network covering the whole city, strengthen primary care, and pay particular attention to the women of 1st pregnancy at middle age and the unhealthy pregnant women; 2nd, health and medical sectors should put some funds on improving maternal facilities and equipments, increase maternity staff, and raise the income of maternity workers; lastly, all hospitals should keep the mother and baby in the same ward, and greatest efforts should be made to raise the breastfeeding rate.

Abortion: its contribution to maternal mortality

Every year between 100,000 and 200,000 women die from illicit abortion. In this paper the magnitude of the problem is described, those most at risk are identified and methods of preventing unwanted pregnancy are suggested. It is argued that midwives have a major role to play in family planning counselling and the provision of contraceptive services. Midwives can also reduce maternal mortality by resuscitating women when emergencies arise from incomplete abortion. This paper is based on one originally given at the ICM/WHO/UNICEF pre-congress workshop is Kobe, Japan, October 1990.