Deborah Maine

Too Far to Walk: Maternal Mortality in Context

The Prevention of Maternal Mortality Program is a collaborative effort of Columbia Universitys Center for Population and Family Health and multidisciplinary teams of researchers from Ghana, Nigeria and Sierra Leone. Program goals include dissemination of information to those concerned with preventing maternal deaths. This review, which presents findings from a broad body of research, is part of that activity. While there are numerous factors that contribute to maternal mortality, we focus on those that affect the interval between the onset of obstetric complication and its outcome. If prompt, adequate treatment is provided, the outcome will usually be satisfactory; therefore, the outcome is most adversely affected by delayed treatment. We examine research on the factors that: (1) delay the decision to seek care; (2) delay arrival at a health facility; and (3) delay the provision of adequate care. The literature clearly indicates that while distance and cost are major obstacles in the decision to seek care, the relationships are not simple. There is evidence that people often consider the quality of care more important than cost. These three factors--distance, cost and quality--alone do not give a full understanding of decision-making process. Their salience as obstacles is ultimately defined by illness-related factors, such as severity. Differential use of health services is also shaped by such variables as gender and socioeconomic status. Patients who make a timely decision to seek care can still experience delay, because the accessibility of health services is an acute problem in the developing world. In rural areas, a woman with an obstetric emergency may find the closest facility equipped only for basic treatments and education, and she may have no way to reach a regional center where resources exist. Finally, arriving at the facility may not lead to the immediate commencement of treatment. Shortages of qualified staff, essential drugs and supplies, coupled with administrative delays and clinical mismanagement, become documentable contributors to maternal deaths. Findings from the literature review are discussed in light of their implications for programs. Options for health programs are offered and examples of efforts to reduce maternal deaths are presented, with an emphasis on strategies to mobilize and adapt existing resources.

MATERNAL MORTALITY-A NEGLECTED TRAGEDY: Where is the M in MCH?

Despite increasing attention to maternal and child health programs most do little to reduce maternal mortality. In developing countries maternal death rates of 100-300/100000 births are common; rates are even higher in rural areas. Only 1 of the components of most maternal-child health programs (oral rehydration growth monitoring breastfeeding family planning and immunization) can reduce maternal mortality--family planning. Women who have many births or give birth at either extreme of the reproductive cycle are more likely to die of complications than other women. If all women who want to limit their families had access to efficient contraception matenal mortality would be substantially reduced. Also needed is a major investment in a system of comprehensive maternity care. 75% of obstetric deaths are due to hemorrhage infection toxemia and obstructed labor. Many of these complications occur among women with recognizable risk factors. It is recommended that the World Bank make maternity care 1 of its priorities. The Bank could initiate a program based on the construction of maternity centers in rural areas the recruitment and training of staff for these centers and the provision of supplies and drugs. Because women receiving maternity care can be offered family planning services as well this proposal provides the World Bank with an opportunity to work toward its goal of reduced population growth rates.

The evidence for emergency obstetric care

We searched for evidence for the effectiveness of emergency obstetric care (EmOC) interventions in reducing maternal mortality primarily in developing countries.

A framework for analyzing the determinants of maternal mortality.

Hundreds of thousands of women in developing countries die each year from complications of pregnancy, attempted abortion, and childbirth. This article presents a comprehensive and integrated framework for analyzing the cultural, social, economic, behavioral, and biological factors that influence maternal mortality. The development of a comprehensive framework was carried out by reviewing the widely accepted frameworks that have been developed for fertility and child survival, and by reviewing the existing literature on maternal mortality, including the results of research studies and accounts of intervention programs. The principal result of this exercise is the framework itself. One of the main conclusions is that all determinants of maternal mortality (and, hence, all efforts to reduce maternal mortality) must operate through a sequence of only three intermediate outcomes. These efforts must either (1) reduce the likelihood that a woman will become pregnant; (2) reduce the likelihood that a pregnant woman will experience a serious complication of pregnancy or childbirth; or (3) improve the outcomes for women with complications. Several types of interventions are most likely to have substantial and immediate effects on maternal mortality, including family planning programs to prevent pregnancies, safe abortion services to reduce the incidence of complications, and improvements in labor and delivery services to increase the survival of women who do experience complications.

Structural adjustment and health in Africa.

In response to The Lancets April 14 editorial on structural adjustment and health in Africa it is surprising that the World Bank report did not include maternal mortality as a yardstick for monitoring health standards in Africa: maternal mortality seems to be a better index of social and economic development than perinatal or infant mortality. Obstetric performance was reviewed in parts of Nigeria after the introduction of the structural adjustment program (SAP). In the 1970s and early 1980s the Nigerian economy was buoyant thanks to petroleum exports but when oil prices slumped the government was forced to introduce SAP. As a result most of the costs that had been borne by the government were gradually passed on to individuals of all the sectors affected health seems to have been the hardest hit. Looking at factors that might have been responsible for the rising maternal mortality rate in the Zaria area of Northern Nigeria it was found that between 1983 and 1988 there had been no significant change in the numbers of obstetricians and obstetric residents at the Ahmadu Bello Teaching Hospital; there was a slight rise in the number of midwives. However the number of deliveries in 1988 was only 46% of the figure for 1983 and the proportion of obstetric admissions that were complicated more than tripled. Maternal deaths at the hospital numbered 48 per year in 1983-85 and 75 in 1988 an increase of 56%. These changes in obstetric indices may not be unrelated to financial policies in hospital care. In 1983 all aspects of maternity care at the hospital were free. In 1985 following the reduction in government subsidy fees were introduced for some services leading to a fall in the number of pregnant women attending the hospital. By 1988 patients were asked to pay for their treatment; with the mean interval between admission and surgery increasing significantly and contributing to the high maternal morbidity and mortality rates in Zaria. (Full text modified)

Emergency obstetric surgery performed by nurses in Zaire.

In rural northwestern Zaïre nurses at Karawa and Wasolo hospitals were trained to do caesarean sections, laparotomies, and supracervical hysterectomies. In Karawa 278 of 321 caesarean sections were done by nurse-surgeons in 18 months, with two deaths. In Wasolo all 32 caesarean sections in 13 months were done by the nurse-surgeons, with 1 death. Of the 37 laparotomies done in both centres, 16 were by nurse-surgeons, and there were two deaths. Four of the five deaths were attributable to protracted labour with septicaemia (1), postoperative infection (2), and protracted labour with no blood pressure on admission (1). Obstetric operations could safely be performed by specially trained nurses in rural areas of developing countries and the high maternal mortality rate in such areas could thus be reduced.

Suicide during pregnancy and its neglect as a component of maternal mortality

Objectives: To raise awareness about the socio‐cultural factors which may lead pregnant women to commit suicide. Methods: This paper reviews and compiles current international literature on this topic, and suggests comparison with evidence from the past. Results: Suicide during pregnancy is often due to the limited choices women face when confronted with an unwanted pregnancy. Neglect of this subject is due in part to the exclusion of suicide from classification as ‘maternal death,’ and other difficulties in collecting reliable data. Conclusions: The problem of suicide during pregnancy underscores the need for sex education at an early age, access to family planning, and access to safe abortion services.

Spousal veto over family planning services.

In many countries a spouse, usually the husband, can veto a partners use of family planning services. Where spousal veto acts as a barrier to family planning services it represents a serious threat to the lives and health of women and children. Removal of spousal authorization requirements has been shown to increase the use of family planning services. The Family Guidance Association of Ethiopia, for example, removed their requirement in 1982 and clinic utilization increased by 26 per cent within a few months. Courts of several countries have held that spousal veto practices violate principles of personal privacy and autonomy and the right to health care. The effect of such judgements has been to reinforce rights to sexual nondiscrimination found, for example, in national constitutions and the Convention on the Elimination of All Forms of Discrimination against Women. This article discusses the nature and application of spousal veto practices, explains how such requirements can violate certain human righ...

The AMDD program: history, focus and structure

The AMDD (Averting Maternal Death and Disability) Program was established at the Mailman School of Public Health in 1999. In this article, we discuss four key aspects of the program: the focus on emergency obstetric care; the use of process indicators; working with partners; and applying human rights.

Program note: Using UN process indicators to assessneeds in emergency obstetric services: Morocco, Nicaragua and Sri Lanka

The indicators are also useful at monitoring changes in availability, utilization and quality. The definitions are summarized in Table 1 and recommended levels can be found in the results tables. The UN indicators developed from an understanding that certain medical services or procedures are necessary to save the lives of women with obstetric complications. These procedures or ‘signal functions’ distinguish facilities that provide