Improving Birth Outcomes Meeting the Challenge in the Developing World (2003) / Chapter Skim
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2. Reducing Maternal Mortality and Morbidity
2. Reducing Maternal Mortality and Morbidity
Pages 41-89
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From page 41... ...
PART 11 Addressing Maternal, Neonatal, and Fetal Morlality and Morbidity
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The vast majority of these deaths are preventable. Researchers also estimate that more than 40 percent of pregnant women experience obstetric disorders that are not immediately fatal (Weil and Fernandez, 1999~.
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In Eastern Africa, as many as 1 woman in 11 dies of pregnancy-related causes, as compared with as few as 1 in 4000 in Western Europe and 1 in 3,500 in North America (WorId Health Organization, United Nations Children's Fund, United Nations Population Fund, 2001~. Table 2-la lists regional and global estimates of the maternal mortality ratio, total annual maternal deaths, and lifetime risk of maternal death.
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.) 45 Lifetime Risk of Maternal Maternal Mortality Maternal Deaths Death Ratioi Annually 1 in: World Total 400 515,000 75 More Developed Countries 21 2,800 2,500 Less Developed Countries 440 512,000 60 Least Developed Countries2 1,000 230,000 16 Africa 1,000 273,000 16 Eastern 1,300 122,000 11 Middle 1,000 39,000 13 Northern 450 20,000 49 Southern 360 4,500 65 Western 1,100 87,000 13 Asia-' 280 217,000 110 Eastern 55 13,000 840 South-central 410 158,000 55 Southeastern 300 35,000 95 Western 230 11,000 95 Europe 28 2,200 2,000 Eastern 50 1,600 1,100 Northern 12 140 3,900 Southern 12 170 5,000 Western 14 280 4,000 Latin America and Caribbean 190 22,000 160 Caribbean 400 3,100 85 Central America 110 3,800 240 South America 200 15,000 150 Northern America 11 490 3,500 Oceania-' 260 560 260 Australia and New Zealand 8 25 5,500 Melanesia 310 560 60 Micronesia Polynesia 33 5 700 1Maternal deaths per 100,000 live births.
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Hemorrhage Hemorrhage primarily postpartum hemorrhage (PPH) is the leading contributor to maternal mortality worIdwide, causing about 24 percent of all maternal deaths (WorId Health Organization, 19991.
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Delivery at home without a skilled birth attendant can result in long delays in obtaining emergency treatment. When the first measures such as use of drugs to stop the bleeding or bimanual compression of the uterus are not taken or are not effective, uterine artery ligation or hysterectomy may be needed, both of which require access to comprehensive essential care services that may involve significant expense and travel.
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From page 48... ...
The risk of puerperal sepsis is higher for women with sexually transmitted and other infections, premature rupture of membranes, retained products of conception, diabetes, cesarean or other operation, postpartum hemorrhage, anemia, poor nutritional status, history of previous complications of labor, and poor infection control. The most common sign of puerperal infection is fever, but a small percentage of women with postpartum fever may have an infection at another site or no infection.
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The disease, which is caused by several diverse types of virus, is endemic in many regions of Asia, Africa, the Middle East, and Central America where sanitation practices are inadequate (Michielsen and Van Damme, 1999~. One form of the disease, hepatitis E, is of greatest concern during pregnancy because of its reported mortality rate of up to 25 percent among pregnant women, compared with a rate of less than 1 percent among the general population (Skidmore, 1997; Aggarwal and Krawczynski, 2000~.
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so cO oD At (a .— o Q O (a ._ ~ ._ ._ Q ~ c-)
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. Obstructed Labor Obstructed labor is estimated to cause 8 percent of all maternal deaths and also presents serious risks for the fetus and neonate (WorId Health Organization, 1999~.
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While such changes are often difficult to achieve, they can be facilitated with information about pregnancy, risks, and healthy behaviors (Harrison, 1997~. Some examples of behavioral changes in women that are discussed in this report include not reproducing after age 35; eating a healthy diet; limiting or avoiding alcohol consumption; stopping smoking; using a bednet to protect against malaria; arranging for a skilled birth attendant at labor and delivery; and recognizing and acting promptly on signs of a complicated delivery.
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1 ~ 1 1 ' 1 I ncreased I ncreased Neonatal Risk for Risk for Health Fetal Neonatal Mortality Mortality FIGURE 2-3 Health care decisions for improved birth outcomes. 53 Unsafe Abortion Increased Risk for Maternal Mortality this report focus on strategies that have proven effective in both clinical trials and in large comparable populations.
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More maternal deaths occur in the much larger group of low-risk women. As a result, antenatal care will not necessarily prevent complications from occurring (Maine and Rosenfield,1999~.
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Although insecticide-impregnated bednets have been shown to reduce malaria infection and death among children (Binka et al., 1997; Lengeler, 2000) , and are provided free of charge to pregnant women in Kenya (Guyatt et al., 2002)
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Guidelines for developing countries compiled by WHO, UNICEF, and the International Nutritional Anemia Consultative Group recommend that all pregnant women receive 60 mg of elemental iron and 400 micrograms of folic acid daily to reduce the prevalence of severe maternal anemia (van den Broek, 1998~. The guidelines also advise prophylaxis against malaria and hookworm for anemic women in areas where these infections are common.
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Prenatal counseling to use a skilled birth attendant Antenatal care can also contribute to successful pregnancy outcomes by encouraging women to obtain skilled care for labor and delivery. According to WHO estimates, more than half of all women give birth without the
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Antenatal care providers can help women and their families finci a place to give birth, a skilled attendant, and the essential items necessary for a clean clelivery. Planning for clelivery should also anticipate complications and the need for referral to an appropriate meclical facility with the appropriate level of good quality essential obstetric care.
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In the committee's judgment, skilled birth attendance has the best evidence so far for reducing maternal and neonatal mortality. Historical trends Maternal mortality in 1870 in much of what is now the developed world exceeded 600 per 100,000 live births, a figure comparable with current maternal mortality ratios in many developing countries (Safe Motherhood Inter-Agency Group, 2000~.
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This was in marked contrast to the United States, where skilled birth attendance was not promoted and maternal mortality remained at 800 per 100,000 live births (Van Lerberghe and De Brouwere, 20011. Figure 2-4 shows the decrease in maternal mortality in Sweden between 1870 and 1900 considered (but not proven)
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Providing a skilled birth attendant during childbirth who has the knowledge and experience to use certain strategies when they are needed is a key step to reducing mortality and severe disability in childbirth. The second key strategy is provision of good-quality obstetric care for complicated deliveries.
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—_ > to So co to Percent of births attended by skilled health staff,1996-1999 FIGURE 2-5 Association of maternal mortality ratio and delivery by a skilled birth attendant. NOTES: Bars: Percent of births with skilled attendance.
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_I = ~_ _ it_ _~ JO 0 0 0 0 0 0 Percent of births attended by skilled staff, 1996-1999 63 FIGURE 2-6 Association of infant mortality rates and delivery by a skilled birth attendant. NOTES: Bars: Percent of births with skilled attendance.
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Although rigorous trials are not available at this time, the committee views the overall association of skilled care with reduced mortality at childbirth, coupled with the need for a skilled birth attendant who can apply the clinical strategies identified in this report when they are needed as sufficient grounds for recommending that a skilled attendant assist at every birth. Providing every delivery with an attendant who has certification in the
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Despite the attractiveness of an apparently less expensive option, the ability of attendants without the skills and experience of a skilled birth attendant to reduce maternal, neonatal, and fetal mortality must be established in trials in similar settings before being adopted for a wider population.3 Management of Childbirth The first stage of labor In order to prevent maternal mortality and morbidity associated with prolonged labor, the progress of labor should be monitored. Simple and effective monitoring of labor was first used in Zimbabwe in the 1970s (Philpott and Castle, 1972a; Philpott and Castle, 1972b)
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The central feature of the partograph is a graphical representation of the progress of labor cervical dilatation, descent of presenting part, and duration and frequency of contractions and its relationship to maternal and fetal condition (see Box 2-1~. The pattern of cervical dilatation in normal labor among different ethnic groups is so similar that a partograph is useful throughout the world (Lennox and Kwast, 1995~.
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REDUCING MATERNAL MORTALITY AND MORBIDITY Name Date of admission Time of admission 67 Gravida Para Hospital number Ruptured membranes hours 200 1 90 1 80 1 70 160 Fetal 1 50 heart 1 40 rate 1 30 1 20 110 100 90 80 Amniotic fluid L Moulding L 10 9 ~\~ I I I I I I 1 1 1 ~ ~ I I I I I 1 1 T I I I I I r~ 1 1 1 2 8 Cervix (cm)
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. Blood pressure: Record every four hours and mark with arrows.
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Active management of third-stage labor Delivery of the placenta and membranes is a particularly hazardous part of childbirth for mothers, because of the risk of postpartum hemorrhage (PPH)
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. Three large RCTs have compared postpartum hemorrhage and other outcomes in deliveries with active management of the third stage of labor and those with physiologic management.
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Misoprostol4 is particularly suitable in developing-country settings where oxytocin and ergometrine are unavailable. An essential package of interventions for care during labor and delivery In conclusion, an essential package of interventions for care during labor and delivery should include the following: · Monitoring the progress of labor using a partograph Using aseptic practices · Supporting the birthing position of the mother's choice · Avoiding medical episiotomy unless specifically indicated · Preventing postpartum hemorrhage through active management of the third stage of labor Complications of labor and delivery and provision of essential obstetric care Even when women receive the highest-quality antenatal care and have skilled providers at the delivery, complications can arise and cause maternal, neonatal, or fetal death.
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Massive hemorrhage or true obstructed labor will require a hospital facility with blood transfusion, anesthesia, and the capacity for major surgery (cesarean delivery or hysterectomy.) Even then, basic EOC can save women's lives by stabilizing them before referral and a journey that may take many hours (United Nations Children's Fund, World Health Organization, United Nations Population Fund, 1997~.
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Unfortunately, most of these require parenteral administration and/or refrigeration,5 conditions that make them unsuitable for use in many rural areas of developing countries. Misoprostol, discussed above as a possible means of preventing postpartum hemorrhage as part of active management of third-stage labor, also appears promising as a means of controlling hemorrhage, particularly in low-resource settings.
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While magnesium sulfate has been viewed as a promising drug for low-resource settings because it is inexpensive and relatively easy to produce, its delivery by intravenous drip or intramuscular injection restricts its use. A recent review of randomized trials concluded that there is not enough evidence to establish the benefits and hazards of anticonvulsants for women with pre-eclampsia (Duley et al., 2000~.
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A review of the use of magnesium sulfate for pre-eclampsia concludes that, "There is now international consensus that magnesium is the treatment of choice for preeclampsia and eclampsia, but the mechanism underlying its salutary effect remains debatable" (Greene, 2003~. Management of obstructed labor involves timely interventions, including vacuum extraction, forceps, and cesarean section.
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Reducing both overuse and inappropriate use of interventions during labor and delivery is best addressed by basing clinical practice on a strong evidence base. This requires continuing evaluation of practices through randomized controlled trials and comprehensive education of birth attendants through influential health leaders, provision of educational materials, and audit and feedback (Buckers, 2001~.
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Recommendation 2. Essential obstetric care should be accessible to address complications of childbirth that cannot be managed by a skilled birth attendant.
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While many of the benefits of antenatal care accrue to the fetus and neonate, certain preconceptional and antenatal interventions can significantly reduce maternal mortality and morbidity. Recommendation 4.
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Research on the safety and efficacy of new drugs and drug combinations should target pregnant women. · Trials are needed to compare the effectiveness of intermittent prophylactic antimalarials with early treatment of malaria for women having their first or second baby.
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Many measures that can be taken to improve maternal health from specific medical interventions, to research, to the strengthening of women's socioeconomic status are likely to benefit the fetus and neonate as well. The interventions recommended in this chapter can work in conjunction with interventions that address neonatal and fetal mortality.
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1996. Obstructed labor injury complex: obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world.
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2001. WHO programme to map the best reproductive health practices: how effective is antenatal care in preventing maternal mortality and serious morbidity?
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2001. Can skilled attendance at delivery reduce maternal mortality in developing countries?
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A randomised placebo controlled trial of oral misoprostol in the third stage of labor. British Journal of Obstetrics and Gynaecology 105(9)
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1996. Is antenatal care effective in reducing maternal morbidity and mortality?
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1998. Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial.
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1999. Oral misoprostol for third stage of labor: a randomized placebo-controlled trial.
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, Maternal Health and Safe Motherhood Programme, Nutrition Programme.
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, United Nations Population Fund (UNFPA)
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