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Improving Birth Outcomes: Meeting the Challenge in the Developing World PART II Addressing Maternal, Neonatal, and Fetal Mortality and Morbidity
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Improving Birth Outcomes: Meeting the Challenge in the Developing World Summary of Findings: Reducing Maternal Mortality and Morbidity in Developing Countries More than half a million women, 99 percent of them in developing countries, die each year from pregnancy-related causes, a leading cause of death among women ages 15-49. The estimated lifetime risk of maternal mortality in some developing countries, where 1 in 11 women die as a result of pregnancy or childbirth, is 500 times that in some developed countries. The five most significant direct causes of maternal mortality—hemorrhage, sepsis, unsafe abortion, hypertensive disease of pregnancy, and obstructed labor—together account for about two-thirds of all maternal deaths. Indirect causes, including preexisting conditions exacerbated by pregnancy, account for about 20 percent of maternal mortality. With many maternal deaths occurring at home during childbirth, it is difficult to assemble clear epidemiological evidence that skilled attendance at delivery reduces maternal mortality. However, the overall association of skilled attendance with reduced maternal mortality, coupled with a knowledge of strategies that a skilled birth attendant can use to reduce both the incidence of complications and their severity constitute sufficient grounds to recommend that a skilled attendant assist every birth. Significant reductions in maternal (as well as fetal and neonatal) mortality can be achieved if complications of childbirth are anticipated and addressed promptly by referral to a facility with the appropriate level of good-quality obstetric care. Access to higher-level care also requires a strong referral system that includes communication with, and transport to, referral facilities.
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Improving Birth Outcomes: Meeting the Challenge in the Developing World 2 Reducing Maternal Mortality and Morbidity According to recent estimates, each year more than 500,000 women between the ages of 15 and 49 die of causes related to pregnancy and childbirth—a leading cause of death among women in that age group (Hill et al., 2001; World Health Organization, 1999; Murray and Lopez, 1997; Weil and Fernandez, 1999). Almost all maternal deaths (99 percent) occur in the developing world (World Health Organization and United Nations Children’s Fund, 1996; AbouZahr et al., 1996), and more than half occur in Africa (Hill et al., 2001). 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). Approximately 15 percent of all births are complicated by a potentially fatal condition that requires emergency care (World Health Organization, 1999). When mothers are malnourished or ill, or when they receive inadequate maternity care, their children also face high risks of disease and death (Tinker, 2000). Tinker (1997) estimates that 30 to 40 percent of infant deaths (1.5-2.5 million) could be averted by maternal interventions alone. This burden of death and illness is borne not only by women and their children, but also by the families and communities that depend upon them (Royston and Armstrong, 1989). For women of child-bearing age (15-44), maternal disorders are the leading causes of death, accounting for almost 16 percent of deaths in this age group (Murray and Lopez, 1997). According to the International Classification of Diseases (ICD)-10 definition, maternal death is “the death of a woman while pregnant or within
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Improving Birth Outcomes: Meeting the Challenge in the Developing World 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes” (World Health Organization, 1999). The most frequently cited measure of maternal mortality, known as the maternal mortality ratio (sometimes mistakenly referred to as a “rate”), is the number of maternal deaths in a population that occur during a given year per 100,000 live births. This number, which represents the risk associated with a single pregnancy, differs by a factor of more than 100 between the highest- and lowest-mortality settings and varies widely among developing countries (see Tables 2-1a and 2-1b) (World Health Organization, United Nations Children’s Fund, United Nations Population Fund, 2001). Another useful measure of maternal mortality is lifetime risk—the odds that a woman in a given population will die as a result of pregnancy. 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 (World Health Organization, United Nations Children’s Fund, United Nations Population Fund, 2001). Table 2-1a lists regional and global estimates of the maternal mortality ratio, total annual maternal deaths, and lifetime risk of maternal death. It is important to note that these numbers represent crude estimates at best, since in the regions where the problem of maternal mortality is most acute, it is least likely to be measured accurately (World Health Organization, United Nations Children’s Fund, United Nations Population Fund, 2001; World Health Organization, 1999). The same caveats apply to estimates of maternal morbidity, which has been reported to occur in up to 30 women for every 1 woman who dies from maternal conditions (Donnay, 2000). In the developing world, one in four women suffers from acute or chronic disability related to pregnancy (Donnay, 2000; World Bank, 1999). Surveillance of maternal mortality, along with other pregnancy and birth outcomes, is discussed in detail in Chapter 5. CAUSES OF MATERNAL MORBIDITY AND MORTALITY The five most important direct causes of maternal mortality in developing countries are hemorrhage, sepsis, unsafe abortion, eclampsia, and obstructed labor (Figure 2-1). Together these causes account for more than two-thirds of maternal mortality in the world. Indirect causes of maternal death, which are responsible for approximately 20 percent of maternal mortality worldwide, include preexisting conditions such as malaria and viral hepatitis that are exacerbated by pregnancy or its management (World Health Organization, 1999).
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Improving Birth Outcomes: Meeting the Challenge in the Developing World TABLE 2-1a Maternal Mortality Ratio, Maternal Deaths, and Lifetime Risk of Maternal Death: World and Regional Estimates (UNICEF classification of countries used [see Table 2-1b].) Maternal Mortality Ratio1 Maternal Deaths Annually Lifetime Risk of Maternal Death 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. 2Subset of less developed countries. *Australia/New Zealand and Japan have been excluded from the regional totals but are included in the total for developed countries. SOURCE: World Health Organization, United Nations Children’s Fund, United Nations Population Fund, 2001.
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Improving Birth Outcomes: Meeting the Challenge in the Developing World TABLE 2-1b Countries Grouped by UNICEF Regions Industrialized countries Andorra; Australia; Austria; Belgium; Canada; Denmark; Finland; France; Germany; Greece; Holy See; Iceland; Ireland; Israel; Italy; Japan; Liechtenstein; Luxembourg; Malta; Monaco; Netherlands; New Zealand; Norway; Portugal; San Marino; Slovenia; Spain; Sweden; Switzerland; United Kingdom; United States of America. Developing countries Afghanistan; Algeria; Angola; Antigua and Barbuda; Argentina; Armenia; Azerbaijan; Bahamas; Bahrain; Bangladesh; Barbados; Belize; Benin; Bhutan; Bolivia; Botswana; Brazil; Brunei Darussalam; Burkina Faso; Burundi; Cambodia; Cameroon; Cape Verde, Central African Republic; Chad; Chile; China; Colombia; Comoros; Congo; Congo, Democratic Republic of; Cook Islands; Costa Rica; Côte d’Ivoire; Cuba; Cyprus; Djibouti; Dominica; Dominican Republic; Ecuador; Egypt; El Salvador; Equatorial Guinea; Eritrea; Ethiopia; Fiji; Gabon; Gambia; Georgia; Ghana; Grenada; Guatemala; Guinea; Guinea-Bissau; Guyana; Haiti; Honduras; India; Indonesia; Iran; Iraq; Israel; Jamaica; Jordan; Kazakhstan; Kenya; Kiribati; Korea, Democratic People’s Republic; Korea, Republic of; Kuwait; Kyrgyzstan; Lao People’s Democratic Republic; Lebanon; Lesotho; Liberia; Libyan Arab Jamahiriya; Madagascar; Malawi; Malaysia; Maldives; Mali; Marshall Islands; Mauritania; Mauritius; Mexico; Micronesia, Federated States of; Mongolia; Morocco; Mozambique; Myanmar; Namibia; Nauru; Nepal; Nicaragua; Niger; Nigeria; Niue; Oman; Pakistan; Palau; Panama; Papua New Guinea; Paraguay; Peru; Philippines; Qatar; Rwanda; Saint Kitts and Nevis; Saint Lucia; Saint Vincent/ Grenadines; Samoa; Sao Tome and Principe; Saudi Arabia; Senegal; Seychelles; Sierra Leone; Singapore; Solomon Islands; Somalia; South Africa; Sri Lanka; Sudan; Suriname; Swaziland; Syria; Tajikistan; Thailand; Togo; Tonga; Trinidad and Tobago; Tunisia; Turkey; Turkmenistan; Tuvalu; Uganda; United Arab Emirates; United Republic of Tanzania; Uruguay; Uzbekistan; Vanuatu; Venezuela; Viet Nam; Yemen; Zambia; Zimbabwe. Least developed countries Afghanistan; Angola; Bangladesh; Benin; Bhutan; Burkina Faso; Burundi; Cambodia; Cape Verde; Central African Republic; Chad; Comoros; Congo, Democratic Republic of; Djibouti; Equatorial Guinea; Eritrea; Ethiopia; Gambia; Guinea; Guinea-Bissau; Haiti; Kiribati; Lao People’s Democratic Republic; Lesotho; Liberia; Madagascar; Malawi; Maldives; Mali; Mauritania; Mozambique; Myanmar; Nepal; Niger; Rwanda; Samoa; Sao Tome and Principe; Sierra Leone; Solomon Islands; Somalia; Sudan; Togo; Tuvalu; Uganda; United Republic of Tanzania; Vanuatu; Yemen; Zambia. SOURCE: World Health Organization, 2001. Hemorrhage Hemorrhage—primarily postpartum hemorrhage (PPH)—is the leading contributor to maternal mortality worldwide, causing about 24 percent of all maternal deaths (World Health Organization, 1999). In some regions, such as certain Chinese provinces, hemorrhage is reported to account for nearly half of all maternal deaths (Kwast, 1991a). In Indonesia, excessive postpartum bleeding (self-reported) occurs in 7 percent of live births (Central Bureau of Statistics et al., 1995).
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Improving Birth Outcomes: Meeting the Challenge in the Developing World FIGURE 2-1 Global estimates of the causes of maternal deaths. SOURCE: World Health Organization, 1999. PPH is the excessive loss—usually of 500 milliliters or more—of blood from the genital tract within 24 hours of delivery (World Health Organization, 1998). If uncontrolled, hemorrhage can quickly lead to shock and death, which generally occurs within 7 days of childbirth. Because of the difficulty of measuring blood loss, a more practical definition of PPH is any blood loss that causes a physiological change such as low blood pressure that threatens a woman’s life (McCormick et al., 2002). Immediate PPH is most commonly due to uterine atony, inadequate contraction of the uterus, and a retained placenta or placental fragments (McCormick et al, 2002). Other causes include damage to the genital tract such as cervical tears, perineal lacerations, and episiotomy. Even relatively mild PPH can aggravate existing anemia caused by poor nutritional intake of iron and folate, hookworm infestation, malaria, or repeated short birth intervals. Women who survive hemorrhage frequently suffer from chronic anemia. Severe anemia, common in developing countries, contributes to high mortality from postpartum hemorrhage. 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. When blood transfusions are required, women are
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Improving Birth Outcomes: Meeting the Challenge in the Developing World exposed to the risk of infection with HIV, hepatitis B, C, and D, malaria, syphilis, cytomegalovirus, and other agents if blood supplies are unscreened and unsafe. INFECTIONS1 Sepsis The second leading cause of maternal mortality, sepsis, is estimated to cause 15 percent of all maternal deaths worldwide (World Health Organization, 1999). Puerperal infections are caused by transfer of an infectious agent from the cervix or vagina to the uterus during labor or pelvic examination or by transfer of bacteria from skin, nostrils, and perineum by contaminated fingers or instruments (AbouZahr et al., 1998). 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. Coupled with the unavailability and inappropriate use of effective antibiotics, relatively minor puerperal infections can rapidly become life-threatening. Women who survive puerperal sepsis are frequently left to cope with chronic ill health due to pelvic pain, dysmenorrhoea, menorrhagia, and/or infertility (AbouZahr et al., 1998). Information on the incidence and outcome of puerperal sepsis is limited because the majority of women in developing countries deliver at home or are in a clinic or hospital only briefly. Malaria More than 40 percent of the world’s population lives in malarious areas, and 90 percent of the estimated 300 to 500 million malaria cases occur in sub-Saharan Africa (United Nations Children’s Fund, 2000). Malaria in pregnancy has serious health consequences for the newborn, as well as for the mother (see Chapters 3 and 6). Women are more susceptible to malaria infection during pregnancy, but this susceptibility decreases with 1 Perinatal transmission of HIV/AIDS is addressed in Chapter 8. Primary infection of women with HIV/AIDS and infection with tuberculosis, while important, are outside the scope of this report on birth outcomes.
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Improving Birth Outcomes: Meeting the Challenge in the Developing World successive pregnancies (Duffy and Fried, 1999; Miller and Smith, 1998; Brabin, 1983). Where malaria is endemic, adults rarely experience severe illness; however, pregnant women in these populations are at increased risk for high parasitemias and anemia (Miller and Smith, 1998; Diagne et al., 1997). In areas of low malarial transmission, immunity is low, and infection during pregnancy can cause severe disease, including fever and central nervous system complications (Steketee et al., 1996a). HIV infection appears to interfere with the maintenance of pregnancy-specific immunity acquired during first and second pregnancies, placing HIV-positive multigravidae in endemic areas at increased risk for the clinical consequences of malaria (Steketee et al., 1996b; Verhoeff et al., 1999). Viral hepatitis Viral hepatitis is the most common cause of liver disease during pregnancy (Pastorek, 1993). 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). Pregnant women who contract hepatitis E during the third trimester appear highly susceptible to developing a fulminant infection. Even when the mother escapes liver failure, this infection often causes a fetal death (Michielsen and Van Damme, 1999). Unsafe Abortion WHO estimates that about one-quarter of all pregnancies end in abortion, a total of 50 million per year. Of these abortions, an estimated 20 million are performed with unsafe methods, by untrained providers, or by the woman herself (Berer, 2000). About 90 percent of unsafe abortions worldwide occur in developing countries (World Health Organization, 1994a), but there is substantial regional variation in abortion-related mortality, as shown in Figure 2-2. In some areas of Africa, where unsafe abortion exacts the highest death toll, it has been found to contribute to between 20 and 50 percent of maternal mortality (Rogo et al., 1999; Benson et al., 1996; Okonofua, 1997). Unsafe abortion can lead to a variety of complications, including sepsis, hemorrhage, genital and abdominal trauma, tetanus, perforated uterus, and poisoning from abortifacient medicines (Maine et al., 1994; Bernstein and Rosenfield, 1998; Brabin et al., 2000; Rochat and Akhter, 1999). These
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Improving Birth Outcomes: Meeting the Challenge in the Developing World FIGURE 2-2 Global estimates of maternal mortality due to unsafe abortion. SOURCE: Wulf, 1999.
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Improving Birth Outcomes: Meeting the Challenge in the Developing World complications have been estimated to result in at least 70,000 maternal deaths per year, accounting for at least 13 percent of all maternal mortality (Bernstein and Rosenfield, 1998; Maine et al., 1994). Moreover, the treatment of abortion complications consumes a disproportionate share of limited health care resources in developing countries (AbouZahr and Ahman, 1998). For example, in Bolivia in the late 1980s, treatment of abortion complications was reported to consume 60 percent of national spending for obstetric and gynecological care (Maine et al., 1994). Hypertensive Disease of Pregnancy Eclampsia is estimated to cause approximately 12 percent of all deaths due to pregnancy-related causes in developing countries (World Health Organization, 1999). A review of hospital-based studies on maternal mortality associated with hypertensive disorders in Africa, Asia, Latin America, and the Caribbean revealed similar rates—between 10 and 15 percent of all maternal deaths—among all regions. In Pakistan, where maternal mortality due to eclampsia has reached an estimated 500 deaths per 100,000 live births, a hospital-based study showed eclampsia to occur in 1 of every 60 deliveries (Jamelle, 1997). Several studies suggest that mortality associated with hypertensive disease of pregnancy is more difficult to prevent than deaths due to other pregnancy-related causes (Duley, 1992; Moodley, 1990; Loudon, 1991). Obstructed Labor Obstructed labor is estimated to cause 8 percent of all maternal deaths and also presents serious risks for the fetus and neonate (World Health Organization, 1999). Its incidence varies widely and is particularly high where levels of nutrition are poor and early marriage is common (Kwast, 1992; Konje and Ladipo, 2000). Obstructed labor can often be anticipated, as it is caused by mechanical factors. Women whose growth has been stunted by malnutrition or untreated infection or who bear children before pelvic growth is complete are at greatest risk for cephalopelvic disproportion, disproportion between the size of the infant’s head and the bony birth canal, which is the main cause of obstructed labor; fetal malpresentation is another, less common cause (Kwast, 1992). Prolonged obstructed labor may produce injuries to multiple organ systems, such as vesico-vaginal or recto-vaginal fistulae, and is associated with increased risk of sepsis, hemorrhage, and uterine rupture (Arrowsmith et al., 1996; Konje et al., 1992). In the developing world, women who suffer physical injuries with long-term sequelae resulting from prolonged obstructed labor may also face serious social problems, such as divorce;
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Improving Birth Outcomes: Meeting the Challenge in the Developing World The following areas of research have been identified by the committee as key to the continued improvement of maternal and overall birth outcomes. Research priorities that target other topics appear in the corresponding chapters. Studies are needed to determine the burden of disease caused by maternal and neonatal bacterial infections in different settings. Research should include the identification of etiologic agents and their antibiotic susceptibility. Strategies for prevention and treatment should be informed by community-based data, including laboratory evaluations. Simple methods to identify mothers and neonates with presumed bacterial infection (such as algorithms based on patient history and physical findings) are also needed. For areas of the world with limited laboratory capacity, there is a need to develop simple, cost-effective diagnostic tests that can be used in a field setting. Diagnostic capabilities at health centers and referral hospitals must also be strengthened. Large, multicenter trials are needed to examine the cost-effectiveness of food and micronutrient supplementation in relation to maternal and neonatal health and fetal survival, particularly in areas where undernutrition is common. Local studies can determine the most effective means of supplementation to improve the nutritional status of the population, and thus of women who become pregnant. Studies are needed to determine whether the level of antibiotic resistance in rural communities is significantly lower than in urban hospitals. Studies are needed to evaluate the targeted use of antibiotics for those women at risk for infection during delivery who cannot be transferred to a hospital or who refuse hospital care. Strategies to prevent malaria during pregnancy are needed, including ways to reduce exposure (e.g., insecticide-impregnated bednets). Antimalarial drug resistance is widespread. 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. These strategies need to be tested in populations where malaria is endemic and women have some acquired immunity and in those where malaria is not endemic and there is less acquired immunity. Trials are needed to identify more effective approaches to accomplishing behavior changes that reduce risks for adverse birth outcomes. The behavioral changes sought include stopping smoking, avoiding pregnancy over the age of 35 years, and recognizing the need for skilled care in pregnancy.
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Improving Birth Outcomes: Meeting the Challenge in the Developing World CONCLUSION The wide gap between MMRs in developed countries and developing countries, where the vast majority of maternal deaths occur, suggests that much can be done to improve maternal survival. The two central, interdependent elements of any strategy to improve maternal health are the provision of skilled assistance for every delivery and access to essential obstetric care for complicated cases. Efforts to improve maternal outcomes could be greatly strengthened through programs of antenatal and postpartum care focused on the prevention and recognition of complications of pregnancy and childbirth. Substantial reduction of maternal mortality and morbidity will require long-term investment in community education and family planning and, ultimately, the empowerment of women. 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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