COMBACEPH - Your Partners In Reproductive Health Care

SAFE MOTHERHOOD
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Maternal mortality and morbidity arising from childbearing exact a heavy, needless toll on women and their families. Nearly 600,000 women die of pregnancy –related causes each year. Ninety-nine percent (99%) of these deaths occur in the developing world as a result of pregnancy-related complications. However, maternal deaths do not make headlines because they occur a few at a time, in poor, remote districts, among poor women who often live in small villages.

A woman’s lifetime risk of dying from pregnancy-related complications or during childbirth is 1 in 48 in the developing world, while it is only 1 in 8,000 in the developed world (1997, World Population Data Sheet). A healthy mother is an asset to every family, as there are only few men who can claim that they can cope adequately in the care of the household in the event of illness, travel or death of the mother.

It was only in the late 1970’s and early 1980s that data coming in on maternal mortality began to unveil the full magnitude of the problem. In 1987 in Nairobi at an International Conference, the safe motherhood initiative was instituted to enhance the quality and safety of girls and women’s lives through the adoption of a combination of health and non-health strategies. The safe motherhood initiative is intended to help countries develop and implement effective and affordable approaches.

Contributory Factors - Women’s Status

Low priority of women’s needs
Illiteracy
Physical abuse and sex exploitation
Neglect due to gender bias starting from conception
Socialized into ignoring their own health needs
Denial of equal social, legal and economic status and decision making
Requires permission from other family members to travel, spend money or seek assistance

Logistical Barriers

Long distances
Limited transport opportunities
Lack of money for transport or care
Lack of childcare arrangements

Traditional Beliefs

Women should be confined during pregnancy, preventing travel and clinic visits
Bleeding is cleansing process which should not be interrupted or treated
Obstructed labour is caused by adultery during pregnancy, requiring confession or the services of a diviner
Specific foods including those that are nutrient rich should be avoided e.g. snails, eggs, etc.
Evil spirits or external forces control the length of labour

Health Facility Issues

Lack of confidence in the service provided by an establishment
Inadequate skills of health service staff
Ill-equipped district hospitals
Unavailability of drugs or medical supplies
Lack of privacy or cleanliness
Unreasonable fees
Rural facilities are isolated due to poor infrastructure and communication
Length of time it takes to receive treatment
Shortage of manpower and unequal distribution of health resources, especially in the rural areas

Malnutrition

Poor nutrition leading to substandard health and nutritional anaemia
Certain cultural practices deprive women of essential nutrients – the best of the food is always given to the men and older people.
Food taboos also prevent pregnant women from eating even high protein diet

Early marriages & adolescent pregnancies

By the age of 15 years, 18% of girls in Asia, 16% in Africa and 8% in Latin America are married (Bali, 1995). Risks and obstetric complications are particularly high such as pregnancy-induced hypertension and eclampsia

High Fertility Rate

Cultural practices where mothers of 10 children are honoured or the husband encourage high fertility
Religious beliefs prevent some women from making use of family planning services

Medical Conditions that cause or contribute to maternal death and morbidity are typically divided into two categories: direct and indirect

Leading Causes of Maternal Death

The five conditions known as the direct causes of maternal mortality are:

1. Haemorrhage- (heavy bleeding), can occur in pregnancy or after delivery, and is generally a result of prolonged labour, uterine rupture or early separation of the placenta from the uterine wall. Postpartum causes of hemorrhage include a retained placenta, tears of the uterus or failure of the uterus to contract

Description of problem
Leading cause of maternal death; extreme blood loss can lead to shock, severe anaemia, cardiac failure and ultimately death within minutes or hours.

2. Sepsis or ruptured uterus - is a serious infection caused by unhygienic practices or unclean instruments used in the birthing process or postpartum period. It often follows abortions/miscarriages, prolonged labour or ruptured membranes.

Description of problem
Contributes to 15% of maternal deaths, often setting in within 2-4 days of delivery. Sepsis can cause shock, premature labour, pelvic inflammatory disease (PID), and infertility.

3. Unsafe abortion and ectopic pregnancy - Unsafe Abortions result from abortions performed under unhygienic conditions with unsterilized tools, or the use of dangerous, sometimes poisonous, methods to induce abortion.

Description of problem
Complications include incomplete abortion (tissue remains in the uterus leading to infection), heamorrhage, RTIs, uterine perforations and infertility. Death usually results from heamorrhage or sepsis.

4. Hypertensive disorders of pregnancy (pregnancy-induced hypertension and eclampsia)- Pregnancy-induced hypertension (pre-eclampsia) tends to occur during the latter stages of pregnancy and in young women having their first pregnancy. The onset of pre-eclampsia is usually swift and without warning; if left untreated, it can lead to eclampsia.

Description of problem
Contributes to 12% of maternal deaths; characterized by high blood pressure, fluid retention (swelling in face, hands), and protein in the urine.

5. Eclampsia, or fits, the more serious condition, occurs late in pregnancy, during delivery or shortly after. Sometimes preceded by spots before eyes, vomiting, and severe headaches; eclampsia results in convulsions.

Description of problem
If eclampsia is left untreated it can result in kidney damage, heart failure, cerebral heamorrhage; it results in as many as 50,000 maternal deaths a year worldwide.

6. Obstructed labour occurs when the infant’s head is too large to pass through the birth canal either due to a sizeable baby, an immature (small) birth canal or the abnormal position of the foetus.

Description of problem
Can cause prolonged labor, exhausting mother and child and leading to shock; vaginal fistula (hole between vagina and rectum or bladder allowing seepage of urine or faeces); uterine tear/rupture, or prolapse (weakened muscles holding womb); and sepsis.

Indirect Causes of Maternal Death

A series of conditions or indirect causes including

anaemia,
malaria,
hookworm,
hepatitis B, and
STI/RTIs,

contribute individually and collectively to almost 20% of maternal deaths

Conditions that Contribute to Maternal Death

Anaemia (low blood haemoglobin (iron) concentration) results primarily from iron deficiency, folic acid deficiency, malaria, parasitic infection and repeated pregnancies. Women’s iron requirements are higher in early adolescence and pregnancy which increases the effects of anaemia.

Description of problem
Over 60% of pregnant women in developing countries are anaemic. Anaemia makes these women 5 times as likely to die from pregnancy-related causes and can lead to miscarriage or premature labour; a greater susceptibility to post-delivery infections; heart failure or circulatory shock at the time of labour and delivery and death from blood loss during delivery.

Malaria infection is transmitted through mosquito bites; the Plasmodium falciparum malaria is the most dangerous.

Description of problem
Pregnant women appear more susceptible to malaria infection. Loss of red blood cells can cause severe anaemia, miscarriage, premature labour, stillbirth, low birth weight babies and death.

Hookworms are parasites that attach to the wall of intestines and feed on red blood cells, causing blood loss and, subsequently, iron loss.

Description of problem
Over 1 billion women in the developing world are infected. As a major factor in causing iron deficiency, hookworm infection contributes to anaemia.

Viral hepatitis (hepatitis B) is associated with malnutrition and poor sanitary conditions and is transmitted through contact with blood and body fluids.

Description of problem

Leads to premature labour, liver failure or severe heamorrhage; occurs more often among pregnant than non-pregnant women and is 3.5 times more likely to be fatal.

STIs/RTIs are passed through sexual intercourse and include diseases such as gonorrhea, syphilis, chancroid or genital sores, genital herpes, genital warts, trichomonas. Often these diseases are symptomless, making them difficult to detect and treat.

Description of problem
Leads to pelvic inflammatory disease, stillborns, ectopic pregnancy, infertility or can be transmitted to the newborn leading to complications.

HIV, an STI, can be transmitted sexually through contaminated blood products, or from an infected mother to her child during delivery or through breast milk.

Description of problem
Eventually HIV leads to AIDS. Presently there is no cure for AIDS, which results in death for the mother and infected offspring.

What can be done to make motherhood safer?

Increase access to family planning and contraceptive services.

Family planning can prevent many maternal deaths by helping women prevent unintended pregnancies and by reducing their exposure to the risks involved in pregnancy and childbirth. Family planning also allows women to delay mother hood, space births and prevent unsafe abortions and protect themselves from sexually transmitted diseases.

Improve the quality of prenatal care

In most developing countries women receive some kind of health care during pregnancy but this care is not effective. Prenatal care should include screening and treatment for anaemia, pregnancy-induced hypertension and STIs. Prenatal counseling also gives women information about appropriate diet and healthy behaviours.
Prenatal Education should be reinforced as well as health and nutrition education. Nutritional supplements must be given such as Iron, Folic acid, Vitamin A, etc. Tetanus toxoid and other immunizations must be given. Each pregnant woman should have at least four prenatal contacts.

Each girl should have equal access to nutrition, health service and education.
Each adolescent should have access to reproductive health information.
Appropriate screening and counseling sessions to detect genetic disorders.

Pre-Conception Care

Appropriate Immunizations against Tetanus and Hepatitis B.

Ensure recognition of complications of pregnancy and delivery

Many women, especially in rural areas, live far from sources of adequate obstetric care. Families and birth attendants need to be aware of warning signs of complications and must act quickly to get women in need to health facilities. Communities should have specific plans for transporting those who suffer complications during childbirth.

Ensure access to essential obstetric care

Trained midwives can manage or stabilize some complications e.g. providing women with antibiotics for infections or with injections to prevent excess bleeding. Midwives can also play an important role in community education and providing referrals to health facilities. They should also be trained to provide essential obstetric care such as ability to perform surgery and provide anaesthesia, blood transfusion and IV infusions, manual removal, logistical support and good supervision.

There should be standard protocols for managing complicated deliveries. There should be health facilities at all levels such as community, health centres and district hospitals.

Provide post-abortion care

Many women die of complications related to unsafe abortions. Women who have unsafe abortions need access to care to treat complications such as infections, incomplete abortions, haemorrhages and injuries to the cervix and uterus. Even in countries where abortion is legal, the services are often difficult to obtain because of stigma and cost of the services

Provide post-partum care for mother and baby

Immediate post-partum care can detect and manage problems arising after delivery such as haemorrhage, infection and problems with breastfeeding.

Raise awareness of safe motherhood

Lack of political commitment at either the national or local level can undermine efforts to strengthen safe motherhood. It is important to create awareness about maternal mortality to ensure commitment in the public and private health sectors. It should be inter-sectoral in approach.

Raise the status of women

Women must be empowered and be able to make decisions on their own reproductive health. Improving female education and employment opportunities would enhance the ability of women to manage their lives and health better and take better motherhood decisions.

CONCLUSION

Safe motherhood initiative is a global concern and every effort should be made to involve all sectors of the community. A healthy mother is an asset to every family. Maternal mortality and morbidity has family, productivity and development impacts.

References
Ampofo, D. A.(1993). The Health Issues of Human Reproduction of Our Time. Accra, The National Science and Technology Press (NASTEP).

Huddart, J. A., Lyons, J. V., Bjerregaard, D. (1999). Integrating Reproductive Health into NGO Programs: Safer Motherhood for Communities, Vol. 2. pp 6 – 13.

Measham, H. B. (1987). “The Safe Motherhood Initiative: Proposals for Action”. Washington: World Bank.

Ransom, E. (1997). Making Pregnancy and Childbirth Safer. Washington, Population Reference Bureau.

Wallace, H. M., Giri, Serrano, C. V. (1995). Health Care of Women and Children in Developing Countries, 2nd Ed. California: Third Party Publishing Co.