4

Obstetric Morbidity and Mortality

This section addresses the health risks of pregnancy and childbearing faced by women in Sub-Saharan Africa, and the factors that exacerbate or mitigate those risks. Maternal mortality and morbidity are reviewed as public health problems, and their causes, prediction, prevention, and cure are examined.

The likelihood that a woman will experience a maternal death is directly to related to the number of times she is pregnant. Because contraceptives permit couples to plan their pregnancies and elect when to have children, the role of family planning in maternal health is discussed, as is the role of unsafe abortion.

The chapter also reviews breastfeeding and its implications for maternal health. While the benefits of breastfeeding for infants are well established, it places considerable demands on their mothers, consuming substantial proportions of their protein, caloric, and mineral intake. Since many African women are nutritionally compromised, the question of whether lactation has a detrimental effect on their overall health status is not trivial. The risk of transmitting HIV infections from mother to infant through breast milk compounds the dilemma.

Another dilemma addressed in this chapter is the tension between the beneficial aspects of traditional medical practices and those that are physiologically detrimental. Significant among the latter is the category of traditional practice that includes female circumcision.

The chapter closes with a section on menopause, a topic that should command increasing attention as more and more African women survive to enter this phase of their lives.

The specific focus on this chapter is obstetric health. The powerfully related and equally important topic of the sexually transmitted diseases is covered in Chapter 11. Because this chapter emphasizes the reproductive period of the female life span, no separate attention is given to that period in the following discussion of the life span approach.

GENDER BURDEN

Chapters 3 through 11 of this report all begin with a summary table that compares the relative burden of a given health problem or set of health problems by gender. At first thought, such a table in this chapter, which deals with the fundamental topic of female reproductive function, would seem neither appropriate nor necessary. Nevertheless, Table 4-1 presents a list of conditions and events that females actually do share with males, in many cases at roughly equal prevalence rates, that are of consequence for females precisely because they are female and because they reproduce. These conditions and events are rarely considered in any unitary way. For that reason,



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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa 4 Obstetric Morbidity and Mortality This section addresses the health risks of pregnancy and childbearing faced by women in Sub-Saharan Africa, and the factors that exacerbate or mitigate those risks. Maternal mortality and morbidity are reviewed as public health problems, and their causes, prediction, prevention, and cure are examined. The likelihood that a woman will experience a maternal death is directly to related to the number of times she is pregnant. Because contraceptives permit couples to plan their pregnancies and elect when to have children, the role of family planning in maternal health is discussed, as is the role of unsafe abortion. The chapter also reviews breastfeeding and its implications for maternal health. While the benefits of breastfeeding for infants are well established, it places considerable demands on their mothers, consuming substantial proportions of their protein, caloric, and mineral intake. Since many African women are nutritionally compromised, the question of whether lactation has a detrimental effect on their overall health status is not trivial. The risk of transmitting HIV infections from mother to infant through breast milk compounds the dilemma. Another dilemma addressed in this chapter is the tension between the beneficial aspects of traditional medical practices and those that are physiologically detrimental. Significant among the latter is the category of traditional practice that includes female circumcision. The chapter closes with a section on menopause, a topic that should command increasing attention as more and more African women survive to enter this phase of their lives. The specific focus on this chapter is obstetric health. The powerfully related and equally important topic of the sexually transmitted diseases is covered in Chapter 11. Because this chapter emphasizes the reproductive period of the female life span, no separate attention is given to that period in the following discussion of the life span approach. GENDER BURDEN Chapters 3 through 11 of this report all begin with a summary table that compares the relative burden of a given health problem or set of health problems by gender. At first thought, such a table in this chapter, which deals with the fundamental topic of female reproductive function, would seem neither appropriate nor necessary. Nevertheless, Table 4-1 presents a list of conditions and events that females actually do share with males, in many cases at roughly equal prevalence rates, that are of consequence for females precisely because they are female and because they reproduce. These conditions and events are rarely considered in any unitary way. For that reason,

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 4-1 Obstetric Health Problems in Sub-Saharan Africa: Gender-Related Burden Problem Exclusive to Females Greater for Females Burden for Females and Males Comparable, but of Particular Significance for Females Anemia   X   Cardiomyopathies     X Diabetes     X Dracunculiasis     X Genital mutilation, sequelae X     HIV/AIDS     X Hypertension     X Iodine deficiency/goiter   X   Leprosy     X Malaria     X Onchocerciasis     X Protein-energy malnutrition     X(?) Schistosomiasis     X Sexually transmitted diseases     X Sickle-cell disease     X Trypanosomiasis     X NOTE: Males obviously do not have obstetric and gynecologic problems. There is, however, a gender difference. While all the health problems listed occur in both males and females, they may be exacerbated by the processes of pregnancy and parturition. This aspect of gender differences needs to be taken into account, both in clinical research and in application. they are listed in Table 4-1 as preexisting or concurrent conditions that, with the exception of genital mutilation, also affect males, but are exclusively female in the way they either exacerbate risk during pregnancy and childbirth, or are exacerbated by those events. The length of this list is impressive. It includes six highly prevalent and burdensome tropical infectious diseases (dracunculiasis, or Guinea worm disease; leprosy; malaria; onchocerciasis; schistosomiasis; and trypanosomiasis); five chronic diseases, one of which is clearly genetic (cardiomyopathies, diabetes, hypertension, rheumatic heart disease, and sickle-cell disease); three nutrition-related conditions (anemia, iodine deficiency, and protein-energy malnutrition); and three conditions related to female sexual identity (HIV/AIDS, the sequelae of female genital mutilation, and the entire group of sexually transmitted diseases). In addition to their sometimes deleterious interactions with the gravid state and the act of parturition, a number of the health problems on this list have vigorous relationships with one another, a dynamic that reappears throughout this chapter and is summarized in the chapter's final table, Table 4-15. THE LIFE SPAN: AN APPROACH TO MATERNAL MORBIDITY AND MORTALITY The basic premise of the life span approach is that the morbidity and mortality associated with reproduction are not haphazard phenomena, but a culmination of events that begin much earlier, even before a woman's own birth. These may include her mother's poor nutritional and health status, intrauterine events, and perhaps lack of adequate prenatal care; her own diet; insult from infectious diseases; injuries and accidents; poor access to health, education, and other resources as she grew up; her work burden; gender discrimination; and the general conditions of poverty. From the time she is conceived to the time she herself conceives, the course of a woman's pregnancy and its outcome will both be affected by a variety of clinical, economic, social, and cultural factors and affect her health and well-being for the rest of her life.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Childhood Episodes of infectious disease in childhood—notably tuberculosis; hepatic infections; rheumatic heart disease; and parasitic infections, especially malaria—often produce long-term sequelae and become chronic conditions (Elo and Preston, 1992). Certain infectious diseases may be more common among females than they are among males, if only because female domestic and productive activities increase exposures in distinctive ways (see Chapter 10). Malnutrition and childhood diarrhea further compromise the female immune system and contribute to recurrent infections during adulthood (Martinez et al., 1990). Poor childhood nutrition has special impact on females: stunting, and correspondingly small pelvic size, places them at risk for obstructed labor (Harrison, 1983; Mosley and Chen, 1984), the most important reported cause of maternal death in Sub-Saharan Africa (WHO, 1991b). Adolescence Adolescence is a period when differences between male and female health status can become striking. At a time when a woman's dietary demands expand because of rapid changes in her physiology, greater energy is required for meeting the mounting volume of taxing adult chores she is expected to assume, chores females are more likely to perform than males (Merchant and Kurz, 1992). Foremost among these new stresses is childbearing. The evidence from the Demographic and Health Surveys (DHS) is that age at marriage in Africa is the lowest among all the world's regions. In Mali, Niger, Nigeria, Senegal, and Uganda, median age at first marriage among women aged 20–24 years at the time of the survey was under 18 years (Robey et al., 1992); the range is from a mean age at marriage of 16–17 in Mali and Niger to a mean of 25–26 in Botswana and Namibia (Guttmacher Institute, 1995). The result of this early marriage is high proportions of teenage pregnancies in most African countries, as well as a larger absolute number of pregnancies simply because a longer period of time is spent in childbearing. That young women are single does not mean they are not having sexual intercourse, and in some cases, that they are not having babies. In the large majority of the Sub-Saharan African countries, a large proportion (37 to 78 percent) of single women ages 15–24 have already had a sexual relationship, and 2 to 42 percent have already had a child. Overall, women are almost as likely to have their first birth before age 20 as they are to marry before age 20. In Botswana, as one instance of what may be a regional phenomenon, the percentage of teenage mothers increased from 15.4 percent in 1971 to 22.6 percent in 1984 (Guttmacher Institute, 1995). It is well known that a number of obstetric conditions are more common and more severe in the adolescent female because of her physiologic immaturity and her overall lack of social and economic resources (Harrison et al., 1985a; Liskin et al., 1985; UN, 1989). These include pregnancy-induced hypertension, anemia, malnutrition, cephalopelvic disproportion, vesico-vaginal and recto-vaginal fistulae, difficult delivery, retardation of fetal growth, premature birth, low birthweight, and perinatal mortality (UN, 1989). In a Nigerian study, for example, 17 percent of 14-year-olds developed hypertensive disease, compared with 3 percent of women aged 20–34 (WHO, 1989). In a hospital study in Cameroon, Leke (1989) reported that although adolescents represented only 28 percent of the obstetric population, they accounted for over 70 percent of obstetric complications. The number of young women with these problems can only be expected to grow because of the absolute increase in the size of the adolescent population (Gyepi-Garbrah, 1988). Persistently high birthrates and, even in Sub-Saharan Africa, declining death rates, especially with improving child survival, have led to dramatic growth in the number of adolescent and young-adult Third World males and females in their most sexually active years. The momentum of population growth created by the large numbers of individuals who are currently infants means that this trend will continue for several decades, even if fertility were to drop to replacement levels tomorrow (Germain and Dixon-Mueller, 1992). Although many more girls now attend school than ever before, which serves to extend the premarital period, many still begin sexual relations early and are particularly vulnerable to problems they are singularly ill-equipped to handle, notably abortions and sexually transmitted diseases. Rates of abortion among adolescents are high. Studies of hospital records in Congo, Kenya, Liberia, Mali, Nigeria, and Zaire found that between 38 and 68

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa percent of women seeking care for complications of abortion were under 20 years of age (Tinker et al., 1994). At Kenyatta National Hospital, women aged 14 to 25 years, half of the reproductive age group, accounted for 84 percent of all septic abortions (Gyepi-Garbrah, 1988); a Benin City study found that almost 60 percent of maternal deaths from abortion occurred in teenagers, who accounted for over 72 percent of maternal deaths. Rates of sexually transmitted diseases (STDs) are also high among adolescents, and rising dramatically: in Uganda, the highest incidence of STDs is among women aged 15–19 years WHO, 1989). A study in Nigeria reported that 16 percent of the female patients presenting for treatment for STDs were children under age 5, and another 6 percent were aged 6 to 15 (Kisekka and Otesanya, 1988). Together, earlier sexual activity, longer periods of fertility, and growing prevalence of STDs among adolescent females mean that more and younger women are also at greater risk of HIV infection (Over and Piot, 1993). If, as anecdotal reports suggest, older men increasingly target younger women as sexual partners in the belief that they are less likely to be HIV-infected, the level and extent of this particular hazard are even greater. Adolescence for many African women is, then, riskier than it used to be, and it is shorter. The period of adulthood arrives swiftly, and it is almost inevitably the most taxing time of a Sub-Saharan African female's life. An African mother is, more and more, the adult with the primary responsibility for her family, financially and otherwise. At the same time, she is in the peak years of her reproductive potential and will spend approximately half of those years either pregnant or breastfeeding (Raikes, 1989). Menopause and Postmenopause As their life expectancy has lengthened, African women complete their reproductive years only to face both the chronic diseases associated with longevity and possible morbidity accrued from infectious diseases survived in childhood. Respiratory infections, tuberculosis, and diarrhea may once again become significant, as well as other age-related diseases such as arthritis, and trauma-related diseases such as lower-back pain. The ever-larger numbers of African women experiencing menopause are also likely to confront the same or similar reproductive diseases as their agemates in the West, notably the gynecologic neoplasms, most of which reach their statistical peaks in women ages 45 to 60. Data are limited in this area because the study of women's health in all developing countries has been focused on reproductive function and pregnancy outcomes almost exclusively (Baumslag, 1985). THE MAGNITUDE OF PREGNANCY-RELATED MORTALITY AND MORBIDITY Quantification of Maternal Mortality The adequacy of the assessment of maternal mortality depends on the data available. The three principal sources of such data are vital registration, health service statistics, and population-based inquiries. The countries of Sub-Saharan Africa do not differ significantly from other developing nations in this range of sources; the difficulty lies in generally lower levels of coverage, completeness, and reliability (Graham, 1991). Vital Statistics Vital statistics—in particular, death certificates—that could conceivably provide reliable information on cause of death cover less than one-tenth of national populations (Tietze, 1977), predominantly in the more privileged urban areas. They are especially constrained in the region's rural areas, where over 70 percent of African women live and where reports of deaths are typically obtained from next of kin, village chiefs, imams, funeral caretakers, or other untrained individuals (Boerma and Mati, 1989; Rosenfield, 1989; Toure et al., 1992). Many national ministries of health lack the wherewithal to maintain vital registries and may not see such efforts as pressing, given the larger hierarchy of problems they face. These low levels of overall coverage, together with the incompleteness that derives from underreporting and misclassification, seriously limit the value of data from vital

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa registration for studying maternal deaths (Graham, 1991). The only exception in the region is Mauritius, notable for the completeness and coverage of its vital statistics and the long history of their accumulation (Graham, 1991). It is only fair to note that, even when they exist and are highly developed, civil records tend to be error-prone. In assessing incidence of maternal mortality in the United States, in 1984 Smith and colleagues estimated that it has been as much as 20 to 30 percent higher than vital statistics indicated. When compared with death certificates, actual levels of maternal mortality were found to be 27 percent higher within the 42-day period after delivery, and 50 percent higher when that postpartum period was not limited to 42 days (Rubin et al., 1981). Benedetti and colleagues (1985) estimated that over the year of their study in the U.S. state of Washington, maternal mortality had been underreported by 112 percent. A conservative statement would be that estimates of maternal mortality are generally highly variable. Health Services Statistics Despite its significance, pregnancy-related mortality is still an event of limited occurrence in comparison, for instance, with infant mortality (Kwast et al., 1986). Thus, adequate assessment has traditionally been understood to require large sample sizes, ideally followed over an extended period of time. Because this approach is difficult and costly, many estimates of maternal mortality have been based on records of deaths at fixed health facilities. In the case of Sub-Saharan Africa, this method is problematic. Although deaths that occur at lower-level facilities, such as clinics or health posts, should and could be included under health services statistics, they tend to be omitted because of general inefficiencies in health information systems—and, perhaps, concern about who might get blamed for a death. While a number of developing countries have had satisfactory experience with health information gathered by primary health workers, this is still a relatively rare practice among the Sub-Saharan African countries (Graham, 1991; Hill and Graham, 1988). This means that estimates of maternal mortality in the region are principally hospital-based, a major source of bias because only a small proportion of women have access to, and use, hospitals (Boerma, 1987; Graham, 1991). In addition, relatively few women deliver in hospital, so that hospital-based figures are only reflective of the women who die there; they exclude the many women who deliver or die at home and never come to the attention of health care providers. Baumslag (1985) reports that only 2 percent of deliveries are attended by a physician or take place in hospitals; 52 percent are attended by an indigenous practitioner, 40 percent by a family member. In Niger, 84 percent of deliveries are at home (Niger Ministry of Finance and Planning, 1993), as are 62 percent of those in Nigeria (Nigeria Federal Office of Statistics, 1992). Furthermore, those who can afford to go to a hospital may be of higher socioeconomic status, more educated, and more likely to have had access to health care during pregnancy. They are thus at lower risk than women without access to these services. This difference may lead to underestimating community mortality or morbidity levels. At the same time, women who deliver in hospital may also be those at high-risk of complications, so that hospital-based estimates may overestimate the true population experience. It is difficult to calculate the combined impact of these opposing biases. In sum, the figures on pregnancy-related mortality presented in much of the literature may not even approximate the true situation (Boerma, 1987). Population-Based Data The third source of information on maternal mortality in Sub-Saharan Africa is the population-based inquiry; it is also the rarest (Graham, 1991). The gathering of such data anywhere presents conceptual and practical difficulties because the classical approaches used—prospective, retrospective, direct, and indirect, independently or in combination —all have methodological drawbacks (Timaeus, 1991). They also must take into account issues of comparability, sustainability, and cost. The number of longitudinal, population-based studies in Sub-Saharan Africa has been small, and the number that gathered maternal mortality data even smaller (cf. Ghana [Danfa Project]; Kenya [Machakos Project]; The Gambia [Keneba Project]). They have not been analyzed systematically as a group in terms of relevance and expense (Tarimo, 1991), but it is hard to imagine their replication in today's financial and political environments.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Furthermore, there are other considerations peculiar to estimating maternal mortality (Graham, 1991). First, as noted above, the event itself is rare. Second is the problem of the simple omission of events. For example, there may be no reliable informant to provide information on the deceased because of the household breakup that may follow a maternal death (Boerma, 1987; Timaeus, 1991). As also noted above, respondents may withhold information on maternal deaths for social, cultural, religious, or emotional reasons (Graham, 1991). Third, reporting at the household or community level may suffer from the same variation in the definition of maternal death that complicates all assessment, particularly comparative assessment (Graham, 1991; Graham and Airey, 1987; Graham and Brass, 1988; Royston and Armstrong, 1989; WHO, 1987b). According to the World Health Organization's (1977) International Classification of Diseases (ICD-9), ''A maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes" (WHO, 1987b). The more recent definition of maternal mortality in the International Classification of Diseases, Volume 10 (ICD-10), has been revised to include deaths within one full year after termination of pregnancy (Fortney, 1990). Another important definitional issue is related to terminology: although much of the literature refers to maternal mortality rate, very often what it is meant is the ratio of maternal deaths to live births (Fortney, 1987; Winikoff and Sullivan, 1987). The maternal mortality ratio is the number of maternal deaths per 100,000 live births. The numerator is "maternal deaths"; "live births" is the denominator because birth records are the only widely available data that can be used as a proxy for the number of pregnancies in the population. The maternal mortality rate is the number of maternal deaths in one year per 100,000 women of reproductive age (usually defined as 15 to 49). This chapter distinguishes between rates and ratios whenever possible. Alternative Approaches The "sisterhood method," a recent development in the population-based estimation of maternal mortality, overcomes some of the problems raised above (Graham and Brass, 1988). A comparatively simple and low-cost technique, it is particularly suited to situations in which conventional information sources are inadequate and unlikely to improve greatly in the near future. Still in evolution, the method is predicated on surveys that ask adult respondents whether any of their adult sisters have died from pregnancy-related causes. Because it maximizes the number of reported woman-years of exposure to risk, reasonably stable estimates may be calculated based on relatively small samples of respondents. Results from initial field trials and the plausibility of the technical modifications being made suggest real promise for the method in the future (Graham, 1991). A government can opt for gathering information through the sisterhood method or any other data-gathering approach—for instance, retrospective and longitudinal analysis of facility records or perinatal audits (Mbaruku and Bergstrom, 1995) in "sentinel sites" in a number of districts or smaller geographic areas that have been selected as representative of nationwide socioeconomic and ecological realities (Tarimo, 1991). The Burden of Maternal Mortality and Morbidity Significant gains have been made in infant and child survival; less progress has been made in maternal survival. Every year, over half a million women worldwide still die as a result of complications associated with pregnancy or childbirth—about one woman a minute. Nearly 99 percent of these deaths occur in developing countries (WHO, 1991b). Maternal mortality rates in Africa are higher than anywhere else in the world. In Sub-Saharan Africa, 150,000 women a year die of maternal causes, about one every 3.5 minutes. If, on average, a woman in Africa has six children during her lifetime (World Bank, 1992), and women who die in their reproductive years leave an average of two or more children (Herz and Measham, 1987), such mortality probably leaves nearly one million children motherless each year. These losses occur even though pregnancy and childbearing constitute a natural biological process, and the knowledge and means exist to remove or attenuate the hazards associated with that process. Yet women continue to die from hemorrhage, infection, obstructed labor, hypertensive disorders, and abortion, primarily because of

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa lack of proper care, especially during delivery (Rosenfield, 1989; Royston and Armstrong, 1989). While the average number of maternal deaths in developed countries is between 10 and 15 per 100,000 live births, women in less-developed countries record rates of over 100 times this number. This is a much greater discrepancy than that observed in infant mortality rates, and it is the widest disparity in health statistics between developed and developing countries (Mahler, 1987; Rosenfield, 1989). If one considers that documentation of maternal deaths in developing countries is invariably incomplete, then the high figures reported undoubtedly underestimate the magnitude of the problem (Baumslag, 1985; Lettenmaier et al., 1988). Table 4-2 and Figure 4-1 present a summary of maternal mortality ratios in a number of African countries and reveal significant variability among those ratios, with a high of 2,900 deaths per 100,000 live births in Mali and a low of 77 deaths per 100,000 live births in Zimbabwe. Five of the 32 countries for which data are available have ratios of over 1,000 deaths per 100,000 live births, over a hundred times the mortality ratio in the United States (Rosenfield, 1989), and only 12 have ratios under 200 deaths per 100,000 live births. These summary figures do not tell the whole story. Within countries, certain categories of females are at greater risk than others. A very early first birth increases a woman's risk of dying from pregnancy-related causes. Women ages 15–19 face a 20 to 200 percent greater risk of pregnancy-related death than older women, and the younger the adolescent, the higher the risk (WHO, 1989). In Nigeria, for example, women under 15 were found to be 4 to 8 times more likely to die of pregnancy-related conditions than those aged 15–19 (Harrison and Rossiter, 1985); data from Ethiopia indicated that teenage women were twice as likely to die from pregnancy-related conditions as were women ages 20–24 (UN, 1989). In sum, pregnant adolescents have a higher likelihood of pregnancy-related complications and consequent risk of pregnancy-related mortality than women further along in their reproductive years; the risk rises again toward the end of those years. Percent of Pregnancy-Related Deaths and Lifetime Risk of Dying An illustrative measure of the level of maternal mortality is the percent of deaths among women of reproductive age that are pregnancy-related, as well as the lifetime risk of dying from maternal causes. In Asia and Africa, 21 to 46 percent of deaths among women ages 15–49 can be traced to pregnancy, compared with less than 1 percent in the United States (WHO, 1991b). In The Gambia, for example, Billewicsz and McGregor (1981) documented that 29 percent of all deaths of women aged 15–49 between 1951 and 1975 were caused by pregnancy. In a follow-up study in the same country, Greenwood and colleagues (1987) found that the percentage was still high: one out of every eight rural women was still dying in pregnancy or childbirth. The likelihood that a woman will die in pregnancy or childbirth depends on how many times she is pregnant. The lifetime risk of maternal mortality is many times greater than ratios indicate, because the ratio ignores the effect of repeated pregnancies; each pregnancy adds to total lifetime risk (Walsh et al., 1993). Because women in Africa have many pregnancies, their lifetime risk of dying is elevated. WHO (1991b) estimates that, given a maternal mortality ratio of 640/100,000 live births and an average of 6.4 children per woman, the average lifetime risk for a woman is 1 in 21. It can rise as high as 1 in 15, especially in rural areas, where women have more children and many more pregnancies. In comparison, the lifetime chance of a maternal death in North America is 1 in 6.366 (Merchant and Kurz, 1992), and in Bangladesh, it is 1 in 25 to 1 in 49 (Figure 4-2). Overall, pregnancy in Africa is a more hazardous experience than it is in other parts of the world. Estimates of Maternal Morbidity Despite all the difficulties associated with the study of mortality, the study of morbidity is still more complicated. In the context of pregnancy, childbirth, or the puerperium, a death is an unmistakable event. In contrast, an illness associated with those periods of female reproductive life can progress slowly, sometimes imperceptibly; the reproductive origins of long-term or delayed morbidity (such as prolapse) can be tricky to ascertain, and misclassifications are frequent (Liskin, 1992). It is also the case that an illness may not be defined as such because of prevailing views of what is normative (for example, goiter). Many women require some convalescence even after an uncomplicated delivery; postpartum ailments, such as stress incontinence, are seen as unavoidable (Liskin,

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 4-2 Maternal Mortality in Sub-Saharan Africa   Female Population Ages 15–49 (1,000s), 1990 Maternal Mortality/ 100,000 Live Births   Country   Ratio Year Source Angola 2,273 113 1973 a Benin 1,068 160 1981 b Botswana 294 200–300 1981–85 a Burkina Faso 2,065 810 1986 a Burundi 1,237 — — — Cameroon 2,526 430 1980s b Cape Verde 94 107 1980 a Central African Rep 721 — — — Chad 1,323 858 1972 a Comoros 104 500 1980 a Congo, PR of 506 1,000 1971 b Côte d'Ivoire 2,527 — — — Djibouti 92 700 1980s b Equatorial Guinea 84 430 1987 b Ethiopia 10,839 2,000 1972 a Gabon 269 — — — Gambia, The 200 1,500 1984 b Ghana 3,287 500–1,500 1984 a Guinea 1,315 — — — Guinea-Bissau 233 — — — Kenya 4,980 168 1977 a Lesotho 410 — — — Liberia 553 — — — Madagascar 2,542 403 1984 a Malawi 1,946 167 1987 b Mali 1,959 1,750–2,900 1987 a Mauritania 455       Mauritius 306 99 1987 a Mozambique 3,653 300 1981 a Namibia 1,818c — — — Niger 1,704 700 1988 b Nigeria 25,726 800 1988 b Reunion 580c 31 1985 a Rwanda 1,558 210 1982 a Senegal 1,645 600 1981–85 b Sierra Leone 945 450 1980 b Somalia 1,393 1,100 1981 b South Africa 34,492c — — — Sudan 5,562 — — — Swaziland 172 120 1982 — Tanzania 5,855 185 1979–89 a Togo 823 87 1977 — Uganda 3,789 300 1984 b Zaire 8,077 — — — Zambia 1,814 151 1983 b Zimbabwe 2,282 77 1988 a a Civil registration data, government estimates. b Other national estimates. c UN Demographic Yearbook, 1991. SOURCES: Population estimates are from the World Bank, 1992. Maternalmortality ratios are from WHO, 1991b.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa FIGURE 4-1 Maternal mortality in Sub-Saharan Africa. SOURCE: WHO, 1991b.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa FIGURE 4-2 A woman's lifetime risk of maternal death, by region. Around the world, women's lifetime risk of dying from pregnancy-related causes varies 500-fold—from 1 in 20 in tropical Africa to 1 in 10,000 in Northern Europe. Lifetime risk (R) is calculated using the maternal mortality ratio (MMR) and the total fertility rate (TFR). R = 1 -(1 - MMR) (1.2TFR) SOURCE: Lettenmaier et al., 1988.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa 1992; Tahzib, 1989; WHO, 1991a); and health care providers and their clients may define illness in divergent, and sometimes dangerous, ways. Nausea, vomiting, swollen hands, and fatigue are usually considered minor complaints and are rarely addressed (Lettenmaier et al., 1988; Liskin, 1992). Composite conditions, such as "maternal depletion syndrome"—a term that describes the cumulative effects of multiple and frequent pregnancies, overlapping periods of lactation and pregnancy, the burdens of work, and maternal nutritional deficiencies (Herz and Measham, 1987; Merchant et al., 1990)—are hard to quantify and may not be regarded as "maternal" per se. Another issue has to do with attribution. Pregnancy-associated illnesses may be either caused or aggravated by pregnancy. For instance, hypertension found during the course of pregnancy or puerperium may stem from preeclampsia, essential (preexisting) hypertension, or chronic renal disease, and the relative proportions of those etiologies in African women do not seem to follow the patterns found in Americans of African origin (Shaper et al., 1974). In addition, when women are reluctant to seek treatment or supply accurate information, as in the case of clandestine abortion, the nature and level of morbidity is, once more, significantly underestimated. For every maternal death worldwide, it is thought that another 16 women suffer serious health consequences from either pregnancy or childbirth (Mahler, 1987; Royston and Armstrong, 1989). If a similar ratio holds true in Africa, then for the 150,000 women who die each year from those causes, another 2.4 million women incur some morbidity or disability. As in the case of maternal mortality, estimates of maternal morbidity are typically derived from hospital studies. Many women in Sub-Saharan Africa do not present at hospital, for a variety reasons. Women who do present at hospital tend to do so because of an acute condition, even though they may have longer-term problems that may or may not be related to the current pregnancy. This further affects the representativeness and completeness of pregnancy-related morbidity data (Liskin, 1992). Trends Knowledge about trends in maternal morbidity and mortality in Africa is limited, partly because it is difficult and costly to conduct the necessary research once, much less several times. Given the underlying problems of data, the lack of plausible baseline information, and the issues of definition discussed above, it is not surprising that the studies that are available are inconclusive. Only Mauritius reliably demonstrated a downward trend in maternal mortality between 1972 and 1987 (WHO, 1991b). This is a function of the country's pattern of social and economic development, which has fostered such improvements in maternal health (UNDP, 1994) and, as noted earlier, a good system of vital statistics that permit its documentation. In a study of ten hospitals between 1973 and 1985, Chukudebelu and Ozumba (1988) found no consistent pattern of decline in maternal mortality and attributed that finding primarily to data deficiencies. Greenwood and colleagues (1987) encountered no observable improvement in pregnancy outcomes in rural areas of The Gambia during their approximately 20 years of work there. WHO reports that, while there seems to be little evidence of an overall decline in maternal mortality in Africa (WHO, 1987b), maternal mortality declined an average of 4 to 9 percent between 1960 and 1975 in the Americas, Europe, Japan, and selected Asian countries (Petros-Barvazian, 1984). Decline was greatest in countries that had the lowest levels at the start of the study. Part of the lack of significant change in Africa is in some part the result of larger dynamics: political upheaval, civil war, a variety of economic traumas, health system strikes, famine, and disease outbreaks, each of which can do its part to quickly erase any previous health gains. Getting a clear picture of what has actually happened in real epidemiologic terms is also confounded by fertility dynamics and socioeconomic variability. A fall in fertility will automatically "translate" into a fall in the number of maternal deaths, because fewer women will be exposed to the risks of pregnancy in a given period; this does not necessarily mean that the level of obstetric risk has fallen as well, and may vary significantly by socioeconomic subgroup. It is also possible that maternal mortality will fall because of other factors, even when overall fertility rates remain high (Graham, 1991; Winikoff and Sullivan, 1987).

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 4-14 Median Duration of Breastfeeding in Months Among Married Women Aged 15–49   Breastfeeding   Country and Region Any Fulla AFRICA Botswana, 1988 Burundi, 1987 Ghana, 1988 Kenya, 1989 Liberia, 1986 Mali, 1987 Nigeria, 1990 Senegal, 1986 Togo, 1988 Uganda, 1988–1989 Zimbabwe, 1988–1989 18 26 22 21 16 20 20 19 23 20 19 3 5 3 2 1 7 2 4 1 4 2 ASIA AND PACIFIC Indonesia, 1987 Pakistan, 1990–1991 Sri Lanka, 1987 Thailand, 1987 26 20 27 15 1 1 2 1 LATIN AMERICA AND CARIBBEAN Bolivia, 1989 Brazil, 1986 Columbia, 1990 Dominican Republic, 1990 Ecuador, 1987 Guatemala, 1987 Mexico, 1987 Paraguay, 1990 Peru, 1991–1992 Trinidad and Tobago, 1987 17 5 9 6 14 22 8 11 17 6 3 <1 2 1 1 NA 1 1 1 1 NEAR EAST AND NORTH AFRICA Egypt, 1988–1989 Jordan, 1990 Morocco, 1987 Tunisia, 1988 20 12 16 17 2 1 3 3 a Include both exclusive and infrequent and supplemented breastfeeding. <1 = less than 0.5 months. NA = Not available. SOURCE: Robey et al., 1992. extra energy expenditure by the mother, energy she would not expend were she not lactating; the Food and Agriculture Organization of the World Health Organization (FAO/WHO) recommends that lactating women consume an extra 2,090 kJ/d more than nonlactating, nonpregnant women to meet those additional energy demands (FAO/WHO, 1985). Assuming a mother of adequate prepregnancy weight, this translates to roughly 500 kCal/day during the first three postpartum months (Hamilton et al., 1984; Parker et al., 1990). These extra kCals are not easily acquired. Up to 45 percent of the women aged 15–44 in less-developed countries do not consume enough calories daily even in their nonpregnant state (Hamilton et al., 1984), and Sub-Saharan Africa is no exception (see Chapter 3). During times of marginal food availability, lactating mothers

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa appear to adjust physiologically to lower caloric intake without compromising milk quality by mobilizing fat reserves accumulated during pregnancy or by developing other adaptive mechanisms (Hamilton et al., 1984; Jellife and Jellife, 1978). Some research (in The Gambia and Kenya) indicates that even among poorly nourished women, breast milk quality remains good and lactation performance is protected (Frigerio et al., 1991a; van Steenbergen et al., 1984). Other research documents cumulative negative effects of poor nutrition and high parity on milk quality and quantity (Funk et al., 1990; Neuman, et al., 1992; Prentice et al., 1987). This suggests that maternal adjustment does not always entirely accommodate lactation demands. The main indicator of breastfeeding's impact on maternal health appears to be changes in the mother's weight, and there is limited evidence that lactating women lose weight at a higher rate than their nonlactating counterparts. In Kenya, Jansen and colleagues (1984) conducted a longitudinal study of 2,874 women and found that they had lost an average of 2.4 to 2.6 kilograms in weight to subsidize milk production. In Zaire, Pagezy (1983) found that weight loss among lactating women was almost a direct reflection of the baby's weight gain, and that the energy costs of nursing were highest during the first few months. Weight loss may be even more pronounced when there is an overlap between breastfeeding and pregnancy, a situation common in Africa. The results are not always in the same direction: lactating Gambian women lost weight, but only during the rainy seasons because of heavy agricultural work, as did nonlactating women (Paul et al., cited in Hamilton et al., 1984). The effect of lactation on maternal health is difficult to study because of different kinds of resilience in response to stress. Frequent illness among children may result in lower demand for breast milk. Smaller infants demand less milk. Seasonal variation and changes in daily activities further confound the effects (Calloway et al., 1988). Finally, findings from studies conducted in stable environments may not apply in conditions of war or famine. MENOPAUSE Menopause is the cessation of menstruation for a year or more, in conjunction with loss of ovarian function, and normally occurs between ages 40 and 55. Its onset is often accompanied by climacteric symptoms such as hot flashes, excessive perspiration, and chills, and perimenopausal women may also be more prone to headaches, nervousness, agitation, or depression (Judd and Meldrum, 1981; WHO, 1981; Wynn, 1983). Manifestations of the condition can range from mild to severe: hot flashes, as one example, can be severe enough to impair sleep, leading to fatigue and decreased energy. In some women, symptoms last a short time (two years or less in half of menopausal women in the United States (Wentz, 1988); in others, symptoms recur periodically. Loss of ovarian function leads to reduction of estrogen levels, which may be accompanied by vaginal atrophy and pruritus, and dryness and pain during intercourse. In some women, menopause may be associated with cardiovascular degeneration and osteoporosis; others may be have no symptoms because significant amounts of estrogens are still being produced (Judd and Meldrum, 1981; WHO, 1981). The nature of menopause and women's response to its onset have generally not been matters of concern in developing countries. Sub-Saharan Africa is no exception. Nevertheless, because women aged 40 and above now comprise nearly 17 percent of the regional population (U.S. Bureau of the Census, 1995), and, as in other parts of the world, female life expectancy exceeds male life expectancy by several years, it is time to pay some attention to these age cohorts. Evidence in the very scanty literature that does exist is that average age of onset of menopause in Nigerian women is age 48 (Okonofua et al., 1990) and that, at least in parts of Nigeria, the health problems associated with menopause are similar to those experienced in the West. In Ghana, Kwawukume and colleagues (1993) estimated onset of menopause to be approximately 48 years of age as well. Characteristics included hot flashes, palpitations, anxiety, sleeplessness, headaches, frequent urination, depression, irritability, tiredness, weight gain, poor memory, and negative attitudes toward coitus. Circumstances that might make the African experience different, such as general undernutrition and repeated episodes of infectious disease, have not been explored. The potential medical needs of a growing cohort of menopausal and postmenopausal women will at some point present an additional challenge to health budgets that customarily have been constrained, and are likely to remain so. For these systems, and for those who tend to think that African women characteristically die young, topics such as estrogen replacement will seem irrelevant, even effete. At the same time, the needs of this

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa grandmother generation may be increasing or changing, not only because they are living longer, but because societal demands on them are mounting: war and the HIV infections have created a population of orphans who need the grandmothers' care, a requirement for new care taking roles at the very time when they themselves may need new kinds of care. A related issue is that of the chronic, noncommunicable diseases. For instance, very little is known about cancer in women in the postreproductive, or even late reproductive, years in Sub-Saharan Africa. Human papilloma virus (HPV) infections have strong epidemiological links with the genesis of cancer of the cervix, which is the most common female malignancy in Nigeria (Adekunle and Ladipo, 1992) and Zimbabwe (Kasule, 1988). Estimated crude incidence rates of cervical cancer range from 14.0 per 100,000 women in western Africa to 23.2 per 100,000 in eastern Africa, which also had the highest number of new cases in 1980 (Parkin et al., 1988). Harare Central Hospital data on gynecological malignancies between 1981 and 1983 indicated that 78 percent of all malignancies were the result of cervical cancer, almost 99 percent were rural, and 78 percent of cases presented were in the advanced stages (Kasule, 1988). High rates of cervical cancer have been reported from a number of other Sub-Saharan African countries as well. It may prove inappropriate to consider the disease as exclusive to the postreproductive period, because it has been reported in women in their twenties and thirties. Indeed, one of the mysteries of the disease is how an infection that is usually acquired in early adulthood leads to cervical cancer 10, 20, or 30 years later (WHO, 1987a). CONCLUSIONS Table 4-15 summarizes the unfolding of obstetric complications across the female life span in Sub-Saharan Africa. It does not reflect the numerous feedback loops and meshing of different factors and events throughout that span, during the years of active reproduction, and before and after that time. For example, an anemic mother is more likely to have a small baby; small babies often grow up to be small adults, and thus are at increased obstetric risk. Micronutrient deficiencies can affect size and intelligence of the offspring, with implications for their later obstetric performance. Nutrition during infancy affects adult stature, and frequent illness may cause ''failure to thrive" and short stature, which in turn can affect the course of labor. During childhood, nutrition continues to be important and immunizations prevent some diseases. A number of childhood diseases—for example, polio, rheumatic fever, and rickets—may lead to chronic disability, with consequences for pregnancy. As females enter fertile age, nutrition and underlying health persist in their importance, and social factors become more prominent. Marriage during adolescence is likely to result in too early and too frequent childbearing, and early sexual debut outside of marriage increases the risk of unwanted pregnancy and clandestine abortion. In contrast, education elevates self-esteem, delays marriage, and increases the likelihood of health-seeking behavior. As women move through adulthood and full reproductive activity, the many dimensions of male-female relationships, family life, and the character of work interact with cumulative biomedical history and concurrent disease exposures to influence fecundity and pregnancy outcomes; women with some of the long-term sequelae of obstructed labor and female genital mutilation may be divorced and possibly ostracized. When women reach and pass menopause, those with living children have enhanced status; women who do not lack social support. Again, some of the sequelae of childbearing, sexually transmitted disease, and FGM persist or worsen. Ten years ago, this chapter would have concluded by pointing to the topic of childbearing and its implications as a virtual wasteland, at best patchily tended. At the height of the child survival campaigns of the 1980s, however, concerned researchers and professionals observed that the worthiest efforts to promote maternal and child health in developing countries were doing little to reduce mortality and morbidity among mothers (Rosenfield and Maine, 1985). In 1987, the World Bank, World Health Organization, and United Nations Fund for Population Activities sponsored a groundbreaking International Safe Motherhood Conference in Nairobi, Kenya. Out of that event grew collaboration among the Bank, UN organizations, and private institutions to foster operations research on maternal mortality and, in other ways, to advance the goal of cutting maternal deaths in half by the year 2000. Subsequently, the Prevention of Maternal Mortality Network (PMM) was established to engage the capabilities of leading physicians, midwives, and social scientists within Africa in research on the magnitude and causes of maternal mortality and morbidity in their region and to take responsibility for advocating or implementing programs

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 4-15 Ages at Which Obstetric Disorders, and Their Sequelae, Occur in Sub-Saharan African Females CATEGORY Gestation Infancy/ Early Childhood (birth through age 4) Childhood (ages 5–14) Adolescence (ages 15–19) Adulthood (ages 20–44) Postmenopause (age 45+)   Obstructed labor Birth trauma               Rape/economically-coerced sex/ Coerced pregnancy/ very early marriage Very early first pregnancy Induced abortion Obstructed labor             Structural damage Fistula Urinary/fecal incontinence Divorce           Pelvic, other infection Infertility No children, status/loss of social support       Genital mutilation/ structural trauma Obstructed labor, fistula, incontinence, ostracism             Urinary retention Recurrent/chronic urinary tract infection Dysuria, renal infection         Stenosis Dyspareunia/vaginismus Pain, divorce         Sepsis Pelvic infection Infertility No children

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa to promote maternal health (Carnegie Corporation, 1993). Other results of these efforts have included smaller programmatic initiatives that are showing some success, such as the Essential Obstetric Functions at the First-Referral level, greater use of the partogram, and maternity waiting homes. Perhaps more important is that a wider awareness has been created around the sheer numbers involved and their human and economic costs. This chapter has sought to expand the subject of maternal mortality and morbidity beyond the boundaries of customary demography to look at what happens before a female formally enters her reproductive years and after she leaves them. As a result, the research recommendations that follow include probes into aspects of those "pre-" and "post-" years that are important, but remain unexplored. RESEARCH NEEDS While the need for good, insightful, systematic research is constant, research in a resource-poor situation may be more useful if it is focused on design and evaluation of interventions to reduce morbidity and mortality. There is no longer a need for research to determine the clinical causes of maternal deaths or the characteristics of women who die; both are now well known. Research intended to determine the cause of death should focus instead on causes inherent in the health care system. Case analyses, or "audits," and "confidential inquiries" are an effective way to identify where improvements in care could have been made. Simple protocols for use by facilities managers, perhaps based on path analysis or decision-tree models, could reward investment. Because research to establish the level of maternal mortality is expensive and fraught with methodologic difficulty, other indicators of progress, such as those developed by UNICEF (Maine et al., 1992), should be used in country efforts to monitor progress. From a biomedical perspective, it might be possible to develop a few surrogate endpoints that could have large utility in both clinical practice and program evaluation. The manner in which education influences pregnancy outcome is not well understood and requires elucidation. Its correlation with income and residence would need to be inspected as well. Virtually all research into induced abortion and its complications is hospital-based, reveals nothing about girls and women who were unable to obtain medical services, and provides only a dim indication of the magnitude of the problem. Further characterization of the mortality, morbidity, and disability associated with induced abortion is essential. In countries where the prevalence and impact of traditional surgical procedures are not well understood, clinic-level recording of health problems that derive from these interventions could be helpful to policymakers. This recommendation takes into account the limitations of using presenting samples in general, as well as the limitation that, in many countries, large numbers of women do not present for clinical care at all, or certainly are not presenting to male physicians. In these situations, data-gathering would have to be designed for extra-clinical settings. Despite speculation, there is no published evidence of a causal relationship between female genital mutilation and HIV infection, yet transmission from an HIV-infected partner when a scarred vagina is subjected to repeated trauma or lesions is possible. Inclusion of this dimension in other studies of HIV transmission could be helpful in this respect. Imaginative approaches have been taken, in Sub-Saharan Africa and elsewhere, to resolving aspects of health care delivery services that are unresponsive to women's gynecologic and obstetric needs. These, however, have not been documented or catalogued in a practical way that might foster replication. The same can be said for the treatment guidelines and algorithms that have been developed in a number of settings for different levels of care. More of a compilation task than research, such catalogues, well distributed, could be extremely helpful. The degree to which lactation affects mothers in negative ways needs to be better understood and quantified, and means of improving nutrition for lactating mothers, as well as guiding them toward the wisest practice, should be developed and evaluated. Almost nothing is known about the sociocultural or biomedical impact of menopause on African women. Qualitative research is needed to determine the nature and magnitude of its effects, including ethnographic studies to determine the symptomatology and management of menopause-related conditions and to shed light on the

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa options women currently have, or might find helpful. Research into the effects of nutrition and general well-being on the onset of the climacteric symptoms would assist those who would develop policies and programs geared toward their management. REFERENCES Adekunle, A. O., and O. A. Ladipo. 1992. Reproductive tract infections in Nigeria: challenges for a fragile health infrastructure. In Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health, A. Germain, K. K. Holmes, P. Piot, and J. N. Wasserheit, eds. New York: Plenum. Adetunji, J. A. 1992. Church-based obstetric care in a Yoruba community in Nigeria. Soc. Sci. Med. 35(9):1171–1178. Aggarwal, V. P., and J. K. G. Mati. 1982. Epidemiology of induced abortion in Nairobi, Kenya. J. Obstet. Gyn. East. Cent. Afr. 1:54–57. Akingba, J. B. 1971. Abortion, maternity, and other health problems in Nigeria. Nigeria Med. J. 7(4):465–471. Alemu, Z. 1988. Girl mothers. Future 24–25:6–7. Archibong, E. 1991. Illegal induced abortion—a continuing problem in Nigeria. Int. J. Gynaecol. Obstet. 34(3): 261–265. Armon, P. J. 1977. Rupture of the uterus in Malawi and Tanzania. E. Afr. Med. J. 54(9):462–471. Armstrong S. 1991. Female circumcision: fighting a cruel tradition. New Sci. Aziz F. A. 1980. Gynecological and obstetric complications of female circumcision. Intl. J. Gynaecol. Obstet. 17:560. Baasher, T. 1982. Psycho-social aspects of female circumcision. In Traditional Practices Affecting the Health of Women and Children, Background Papers for the WHO Seminar, T. Baasher et al., eds. WHO EMRO Technical Publication 2(2):163–180. Bakr, S. A. 1982. Circumcision and infibulation in the Sudan. In Traditional Practices Affecting the Health of Women and Children, Background Papers for the WHO Seminar, T. Baasher et al., eds. WHO EMRO Technical Publication 2(2):138–144. Baumslag, N. 1985. Women's status and health: world considerations. In Advances In International Maternal and Child Health, D. B. Jellife and E. F. Jellife, eds. Oxford: Clarendon. Beddada, B. 1982. Traditional practices in relation to pregnancy and childbirth. In Traditional Practices Affecting the Health of Women and Children, Background Papers for the WHO Seminar, T. Baasher, et al., eds. WHO EMRO Technical Publication 2 (2). Benedetti, T. J., P. Starzyk, and F. Frost. 1985. Maternal deaths in Washington State. Obstet. Gynecol. 66:99–101. Bhatia, J. 1993. Levels and causes of maternal mortality in a southern state of India Stud. Fam. Plan. 24(5)310–318. Billewicz, W. Z., and I. A. McGregor. 1981. The demography of two West African (Gambia) villages (1951–1975). J. Biosoc. Sci. 13(1):219–240. Blanc, A. 1991. Demographic and Health Surveys World Conference, August 5–7, 1991, Executive Summary. Columbia, Md.: IRD/Macro International. Boerma, J. K. G. 1987. The magnitude of the maternal mortality problem in Sub-Saharan Africa Soc. Sci. Med. 24(6):551–558. Boerma, J. K. G., and J. K. T. Mati. 1989. Identifying maternal mortality through networking: Results from coastal Kenya. Stud. Fam. Plan. 20(5):245–252. Bradley, J., N. Sikazwe, and J. Healy. 1991. Improving abortion care in Zambia. Stud. Fam. Plan. 22(6):391–394. Buchanan, R. 1975. Effects of Childbearing on Maternal Health. Population Reports, Series J, No. 8. Washington, D.C.: George Washington University Medical Center, Population Information Program. Calloway, D. H., S. P. Murphy, C. H. Beaton, et al. 1988. Food intake and human functions: a cross point project perspective of the Collaborative Research Support Program in Egypt, Kenya, and Mexico. University of California, Berkeley. Photocopy. Carnegie Corporation of New York. 1993. Making pregnancy and childbearing safer for women in West Africa. Carnegie Quarterly 38(1). Castle, M. A., R. Likwa, and M. Whittaker. 1990. Observations on abortion in Zambia. Stud. Fam. Plan. 21(4):231–235. Chukudebelu, W. O., and B. C. Ozumba. 1988. Maternal mortality in Anambra State, Nigeria. Int. J. Gynaecol. Obstet. 27:365–370. Coeytaux, F. M. 1988. Induced abortion in Sub-Saharan Africa: what we do and do not know Stud. Fam. Plan. 19(3):186–190. Combs, C. A., E. L. Murphy, and R. K. Laros. 1991. Factors associated with postpartum hemorrhage with vaginal birth. Obstet. Gynecol. 77:69–76. Cook, J. D., M. Carriaga, S. G. Kahn, W. Schalch, and M. S. Skikne. 1990. Gastric delivery system for iron supplementation. Lancet 335:1136–1139. Cook, R. 1982. Damage to physical health from pharonic circumcision (infibulation) of females. In Traditional Practices Affecting the Health of Women and Children, Background Papers for the WHO Seminar, T. Baasher et al., eds. WHO EMRO Technical Publication 2(2):145–154. Crowther, C. 1986. The prevention of maternal deaths: A continuing challenge. Centr. Afr. J. Med. 32(1):11–14. Cutner, L. P. 1985. Female genital mutilation. Obstet. Gynecol. Surv. 40(7):437–443. Dahabo, A. M. 1989. Somalia poem on feminine pain. Inter-African Committee on Traditional Practices Newsletter 7. Defense for Children International. 1991. The Effects of Maternal Mortality on Children in Africa: An Exploratory Report on Kenya, Namibia, Tanzania, Zambia, and Zimbabwe. New York. Dorkenoo, E., and S. Elworthy. 1992. Female Genital Mutilation: Proposals for Change. London: Minority Rights Group International. Dorland's Illustrated Medical Dictionary, 27th Edition. 1988. Philadelphia, Penn.: W. B. Saunders. Egwuatu, V. E. 1986. Childbearing among the Igbos of Nigeria. Intl. J. Gynaecol. Obstet. 24(2):103–109.

OCR for page 80
IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Ekwempu, C. C. 1993. Editorial. Bull. Act. Intl. Med. January. Ekwempu, C. C., D. Maine, M. B. Olorukoba, E. S. Essien, and M. N. Kisseka. 1990. Structural adjustment and health in Africa. Lancet 336:356. El Dareer, A. 1982a. Woman, Why Do You Weep? London: Zed. El Dareer, A. 1982b. A study of the prevalence and epidemiology of female circumcision in Sudan. In Traditional Practices Affecting the Health of Women and Children, Background Papers to the WHO Seminar, T. Baasher et al., eds. WHO EMRO Technical Publication 2(2):312–334. El Dareer, A. 1983. Attitudes of Sudanese people to the practice of female circumcision Intl. J. Epidemiol. 12(2):138–144. Elo, I. T., and S. H. Preston. 1992. Effects of early life conditions on adult mortality: A review. Pop. Index. 58(2):186–212. Ewbank, D. C. 1993. Impact of health programmes on child mortality in Africa: evidence from Zaire and Liberia. Intl. J. Epidemiol. 22(Suppl. 1):S64-S72. Fathalla, M. F. 1987. The long road to maternal death. People 14:8–9. FAO (Food and Agriculture Organization). 1985. Expert Consultation: Energy and Protein Requirements. Geneva: WHO Technical Report Series 724. Feachem, R. G., W. J. Graham, and I. M. Timaeus. 1989. Identifying health problems and health research priorities in developing countries. J. Trop. Med. Hyg. 92:133–191. Fortney, J. A. 1987. The importance of family planning in reducing maternal mortality. Stud. Fam. Plan. 18(2):109–115. Fortney, J. A. 1990. Implication of the ICD-10 definition related to death in pregnancy, childbirth in the pueperium. World Health Stat. Q. 43:246–248. Fortney, J. A., and E. W. Whitehorne. 1982. The development of an index of high-risk pregnancy. Am. J. Obstet. Gynecol. 43:501–508. Frigerio, C., Y. Schutz, R. Whitehead, and E. Jequier. 1991a. A new procedure to assess the energy requirements of lactation in Gambian women. Am. J. Clin. Nutr. 54(3):526–533. Frigerio, C., Y. Schutz, and A. Prentice. 1991b. Is human lactation a particularly efficient process? Eur. J. Clin. Nutr. 45(9):459–462. Funk, M. A., L. Hamlin, and M. F. Picciano. 1990. Milk belenium in rural African women: the influence of maternal nutrition, parity, and length of lactation. Am. J. Clin. Nutr. 51:220–224. Germain, A., and R. Dixon-Mueller. 1992. Stalking the elusive "unmet need" for family planning. Stud. Fam. Plan. 23:330–335. Gordon D. 1991. Female circumcision and genital operations in Egypt and the Sudan: A dilemma for medical anthropology. Med. Anthropol. 5(1):3–14. Graham, W. J. 1991. Maternal mortality: levels, trends, and data deficiencies. In Disease and Mortality in Sub-Saharan Africa, R. G. Feachem and D. T. Jamison, eds. New York: Oxford University Press. Graham, W. J., and P. Airey. 1987. Measuring maternal mortality: sense and sensitivity. Hlth. Pol. Plan. 2(4):323–333. Graham, W. J., and W. Brass. 1988. Field performance of the sisterhood method for measuring maternal mortality. Paper presented at the IUSSP/CELADE Seminar on the Collection and Processing of Demographic Data in Latin America, Santiago, 23–27 May. Greenwood, A. M., B. M. Greenwood, and A. K. Bradley. 1987. A prospective study of the outcome of pregnancy in a rural area of The Gambia. Bull. WHO 65(5):635–643. Greenwood, A. M., A. K. Bradley, P. Byass, et al. 1990. Evaluation of a primary health care programme in The Gambia. I. The impact of trained traditional birth attendants on the outcome of pregnancy. J. Trop. Med. Hyg. 93:58–66. Guttmacher Institute. 1995. Women, Families and the Future: Sexual Relationships and Marriage Worldwide. New York: Alan Guttmacher Institute. Gyepi-Garbrah, B. 1985. Adolescent fertility in Kenya. Boston, Mass.: Pathfinder Fund. Gyepi-Garbrah, B. 1988. Fertility and marriage in adolescents in Africa. Paper presented at IUSSP African Population Conference, Dakar, Senegal, Nov. 7–12. Hamilton, S., B. Popkin, and C. Spicer. 1984. Women and Nutrition in Third World Countries. New York: Praeger. Harrison, K. A. 1983. Obstetric fistula: one social calamity too many. Br. J. Obstet. Gynaecol. 90:385–386. Harrison, K. A. 1985. Child-bearing, health and social priorities: a survey of 22,774 consecutive hospital births in Zaria, Northern Nigeria. Br. J. Obstet. Gynaecol. (Suppl. 5):110–115. Harrison, K. A. 1986. Literacy, parity, family planning and maternal mortality in the Third World. Lancet 2(8511):865–866. Harrison, K. A., and C. E. Roster. 1985. Maternal mortality. Br. J. Obstet. Gynaecol. (Suppl. 5):110–115. Harrison, K. A., A. F. Fleming, N. D. Briggs, and C. E. Rossiter. 1985a. Growth during pregnancy in Nigerian teenage primigravidae. Br. J. Obstet. Gyn. (Suppl. 5):40–48. Harrison, K. A., C. E. Rossiter, H. Chong, et al. 1985b. The influence of maternal age and child-bearing with special reference to primigravidae age 15 years and under. Br. J. Obstet. Gynaecol. (Suppl. 5):25–31. Herz, B., and A. R. Measham. 1987. The Safe Motherhood Initiative: Proposals for Action. World Bank Discussion Paper 9. Washington, D.C.: World Bank. Hill, A. G., and W. J. Graham. 1988. West African Sources of Health and Mortality Information: A Comparative Review. Technical Study 58e. Ottawa: International Development Research Centre. Hosken, F. P. 1982. Female circumcision in the world today: a global review. In Traditional Practices Affecting the Health of Women and Children, Background Papers to the WHO Seminar, T. Baasher et al., eds., WHO EMRO Technical Publication 2(2):195–214. Hurlich, S. 1986. Women in Zambia. Rural Science and Technology Institute, Canadian International Development Institute.

OCR for page 80
IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Ismail, E. A. 1982. Child marriage in Somalia. In Traditional Practices Affecting the Health of Women and Children, Background Papers to the WHO Seminar, T. Baasher et al., eds.. WHO EMRO Technical Publication 2(2):130–133. Jacobson, J. C. 1990. The global politics of abortion. Worldwatch Paper 97. Washington, DC.: Worldwatch. Jamison, D. T., W. H. Mosley, A. R. Measham, and J. L. Bobadilla, eds. 1993. Disease Control Priorities in Developing Countries. New York: Oxford University Press. Jansen, A. A., J. A. Kusin, B. Thiuri, et al. 1984. Anthropometric results in pregnancy and lactation. In Maternal and Child Health in Rural Kenya: An Epidemiological Study J. K. Van Ginneken and A. S. Muller, eds. London: Croom Helm. Jellife, D. B., and E. F. Jellife. 1978. The volume and composition of human milk in poorly nourished communities: A review Am. J. Clin. Nutr. 31(3):492–515. Johns Hopkins University. 1992. Logo materials, distribution survey report, Nigeria. Baltimore: Population Communication Service. Photocopy. Judd, H. L., and D. R. Meldrum. 1981. Physiology and pathophysiology of menstruation and menopause. In Gynecology and Obstetrics: The Health Care of Women, 2nd ed., S. L. Romney, M. J. Gray, A. B. Little, J. A. Merril, E. S. Quilligan, and R. W. Stander, eds. New York: McGraw-Hill. Kaiser Family Foundation. 1993. Reproductive Health Policy and Programs: Reflections on the African Experience—A Conference Report. Harare. Kasongo Project Team. 1983. The Kasongo Project. World Health Forum 4:41–45. Kasule, J. 1988. The pattern of gynecological malignancy in Zimbabwe. Department of Obstetrics and Gynecology, University of Zimbabwe. Photocopy. Kaunitz, A. M., C. Spence, T. S. Danielson, R. W. Rochat, and D. A. Grimes. 1984. Perinatal and maternal mortality in a religious group avoiding obstetric care. Am. J. Obstet. Gynecol. 150:826–831. Keller, M. E. 1987. Maternal mortality in Kamazu Central Hospital for 1985. Med. Q. Malawi 4(1):13–16. Kheir A-HHM, S. Kumar, and A. R. Cross. 1991. Female circumcision: Attitudes and practices in Sudan. Paper presented at the Demographic and Health Surveys World Conference, Washington, D.C. Kisekka, M., and B. Otesanya. 1988. Sexually transmitted disease as a gender issue: Examples from Nigeria and Uganda. Paper presented at the AFARD/AAWORD Third General Assembly, Dakar, Senegal, August. Knippenberg, R., S. Ofosu-Amaah, and D. Parker. 1990. Strengthening PHC Services in Africa: An Operations Research Agenda New York: UNICEF. Koso-Thomas, O. 1985. Female Circumcision: Strategies for Eradication. London: Zed. Kwast, B. E. 1991. Midwives' role in safe motherhood. J. Nurse Midwif. 36(6):366–372. Kwast, B. E., R. W. Rochat, and W. Kidane-Mariam. 1986. Maternal mortality in Addis Ababa, Ethiopia. Stud. Fam. Plan. 17:288–301. Kwawukume, E. Y., T. S. Gosh, and J. B. Wilson. 1993. Menopausal age of Ghanaian women. Intl. J. Gynaecol. Obstet. 40(2):151–155. Ladjali, M., and N. Toubia. 1990. Female circumcision: Desperately seeking a space for women. Intl. Plan. Parenthood Fed. Med. Bull. 24(2). Leke, R. J. 1989. Commentary on unwanted pregnancy and abortion complications in Cameroon Intl. J. Gynaecol. Obstet. (Suppl.) 3:33–35. Lema, V. M. 1990. The determinants of sexuality among adolescent school girls in Kenya E. Afr. Med. J. 67(3)191–200. Lema, V. M., R. K. Kamau, and K. O. Rogo. 1989. Epidemiology of abortions in Kenya. The Center for the Study of Adolescence (CSA), Nairobi. Photocopy. Leslie, J., and G. R. Gupta. 1989. Utilization of formal services for maternal nutrition and health care. International Center for Research on Women, Washington, D.C. Photocopy. Lettenmaier, C. L., L. Liskin, C. Church, and J. Harris. 1988. Mothers' Lives Matter: Maternal Health in the Community. Population Reports, Series L, No. 7 Baltimore, Md.: Johns Hopkins University, Population Information Program. Lightfoot-Klein, H. 1989. Prisoners of Ritual: An Odyssey into Female Genital Circumcision in Africa. New York: Harrington Park. Likwa, R., and M. Whittaker. n.d. The characteristics of women presenting for abortion or for complications of illegal abortions at the University Teaching Hospital, Lusaka, Zambia—An exploratory study. The Population Council, New York. Photocopy. Liskin, L. 1992. Maternal morbidity in developing countries: a review and comments Int. J. Gynaecol. Obstet. 37(2):77–87. Liskin, L., N. Kak, A. Rutledge, et al. 1985. Youth in the 1980's: Social and Health Concerns. Population Reports, Series M, No 9. Baltimore, Md.: Johns Hopkins University, Population Information Program. Mahler, H. 1987. The safe motherhood initiative: a call to action. Lancet (March): 668–670. Mahmood, T. A., D. M. Campbell, and A. W. Wilson. 1988. Maternal height, shoe size, and outcome of labor in white primigravidas: A prospective anthropometric study. Br. Med. J. 297(6647):515–517. Maine, D. 1991. Safe Motherhood Programs: Options and Issues. New York : Center for Population and Family Health, School of Public Health, Columbia University. Maine, D., A. Rosenfield, A. Wallace, A. M. Kimball, B. Kwast, E. Papiernik, and S. White. 1987. Prevention of maternal deaths in developing countries: Program options and practical considerations. Paper presented at the International Safe Motherhood Conference, Nairobi, February 10–13. Maine, D. et al. 1992. Barriers to treatment of obstetric emergencies in rural communities of West Africa. Stud. Fam. Plan. 23(5):279–291. Maine, D., J. McCarthy, and V. M. Ward. 1992. Guidelines for monitoring progress in the reduction of maternal mortality (a work in progress). UNICEF: New York. Martinez, J. M., M. Phillips, and R. G. Feachem. 1990. Diarrheal Diseases: Health Section Priorities Review. Washington, D.C.: World Bank. Mbaruku, G., and S. Bergstrom. 1995. Reducing maternal mortality in Kigoma, Tanzania. Hlth. Pol. Plan. 10(1):71–78.

OCR for page 80
IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Mbizvo, M. T., S. Fawcus, G. Lindmark, and L. Nystrom. 1993. Maternal mortality in rural and urban Zimbabwe: social and reproductive factors in an incident case-reherent study. Soc. Sci. Med. 36(9):1197–1205. McCann, M. F., L. S. Liskin, P. J. Piotrow, W. Rinehart, and G. Fox. 1984. Breastfeeding, Fertility and Family Planning. Population Reports, Series J, No. 24. Baltimore, Md.: Johns Hopkins University, Population Information Program. McGregor, I. A. 1991. Morbidity and mortality at Kenneba, The Gambia, 1950–75. In Disease and Mortality in Sub-Saharan Africa, R. G. Feachem and D. T. Jamison, eds. New York: Oxford University Press. McLean S., and S. E. Graham. 1985. Female Circumcision, Excision and Infibulation: The Facts and Proposals for Change. Report 47. London: The Minority Rights Group. Megafu, U. 1983. Female circumcision in Africa: An investigation of the presumed benefits among Ibos of Nigeria. E. Afr. Med. J. 60(11)793–800. Meheus, A. 1992. Women's health: importance of reproductive tract infections, pelvic inflammatory disease, and cervical cancer. In Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health, A. Germain, K. K. Holmes, P. Piot, and J. N. Wasserheit, eds. New York: Plenum. Melrose, E. B. 1984. Maternal deaths at King Edward VIII Hospital, Durban. S. Afr. Med. J. 65(5):161–165. Merchant, K., M. Reynaldo, and J. D. Haas. 1990. Consequences for maternal nutrition of reproductive stress across consecutive pregnancies. Am. J. Clin. Nutr. 52:616–20. Merchant, K. M., and K. M. Kurz. 1992. Women's nutrition through the life cycle: Social and biological vulnerabilities In Women's Health: A Global Perspective, M. A. Koblinsky, J. Timyan, and J. Gay, eds. Boulder, Colo.: Westview. Miller, J. E., and R. Huss-Ashmore. 1989. Do reproductive patterns affect maternal nutritional status? An analysis of maternal depletion in Lesotho. Am. J. Human Biol. 1(4):409–419. Modawi, O. 1982. Traditional practices in childbirth in Sudan. In Traditional Practices Affecting the Health of Women and Children, Background Papers for the WHO Seminar, T. Baasher et al., eds. WHO EMRO Technical Publication (2):75–87. Mosley, W. H., and L. Chen. 1984. An analytical framework for the study of child survival in developing countries. Pop. Dev. Rev. 10 (Suppl.):25–45. Muller, A. S. and J. K. van Ginneken. 1991. Morbidity and mortality in Machakos, Kenya, 1974–81. In Disease and Mortality in Sub-Saharan Africa, R. G. Feachem and D. T. Jamison, eds. New York: Oxford University Press. Nash, E. S. 1990. Teenage pregnancy—need a child bear a child? S. Afr. Med. J. 77(3): 147–151. Neuman, C., N. O. Bwibo, and M. Jifman. 1992. Functional Implication of Malnutrition, Final Report. Office of Nutrition, United States Agency for International Development Washington, D.C. Nichols, D., O. A. Ladipo, J. M. Paxman, and E. O. Otolorin. 1986. Sexual behavior, contraceptive practice, and reproductive health among Nigerian adolescents. Stud. Fam. Plan. 17(2)100–106. Niger Ministry of Finance and Planning. 1993. Niger Demographic and Health Survey, 1992. Niamey: General Division of Planning, Ministry of Finance and Planning. Nigeria Federal Office of Statistics and Macro International. 1992. Nigeria Demographic and Health Survey. Lagos: Federal Office of Statistics. Eddied, T. O. 1986. Offering an alternative to illegal abortion in Nigeria New Era Nursing Image International 2(2):39–42. Okafor, C. B. 1991. Availability and use of services for maternal and child health care in rural Nigeria. Int. J. Gynaecol. Obstet. 34(4):331–346. Okonfua, F. E., A. Lawal, and J. K. Bamgvose. 1990. Features of menopause and menopausal age in Nigerian women. Intl. J. Gynaecol. Obstet. 31(4):341–345. Okonofua, F. E., A. Abejide, and R. A. Makanjuola. 1992. Maternal mortality in Ile-Ife, Nigeria: A study of risk factors. Stud. Fam. Plan. 23(5):319–324. Oronsaye, A. U., and G. I. Odiase. 1981. Incidence of ectopic pregnancy in Benin City, Nigeria. Trop. Doctor 11(4):160–163. Otoo, S. N. 1973. The traditional management of pregnancy and childbirth among the Ga people, Ghana. Trop. Geog. Med. 25:88–94. Over, M., and P. Piot. 1993. HIV infection and sexually transmitted diseases. In Disease Control Priorities in Developing Countries, D. T. Jamison, W. H. Mosley, A. R. Measham, and J. L. Bobadilla, eds. New York: Oxford University Press. Pagezy, H. 1983. Attitudes of Ntomba society towards the primiparous woman and its biological effects. J. Biosoc. Sci. 15(4):421–431. Parker, L. N. G. R. Gupta, K. M. Kurz, and K. M. Merchant. 1990. Better health for women: Research results from the Maternal Nutrition and Health Care Program. The International Center for Research on Women, Washington, D.C. Photocopy. Parkin, D. M., E. Laara, and C. S. Muir. 1988. Estimates of the worldwide frequency of sixteen major cancers in 1980. Intl. J. Cancer 32:407–415. Petros-Barvazian, A. 1984. World priorities and targets in maternal and child health in the year 2000. Intl. J. Gynaecol. Obstet. 22:439–448. Plummer, F. A., M. Laga, R. C. Brunham, et al. 1987. Postpartum upper genital tract infections in Nairobi, Kenya: epidemiology, etiology and risk factors. J. Infect. Dis. 156:92–98. Prema, K., R. Madhavapeddi, and B. A. Ramalakshmi. 1981. India. Indian Council of Medical Research, National Institute of Nutrition Photocopy. Prentice, A. M., A. Prentice, W. H. Lamb, and P. G. Lunn. 1983. Metabolic consequences of fasting during Ramadan in pregnant and lactating women. Human Nutr. Clin. Nutr. 37C(4):283–294. Prentice, A., T. J. Cole, and R. G. Whitehead. 1987. Impaired growth in infants born to mothers of very high parity. Human Nutr. Clin. 41C:319–325.

OCR for page 80
IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Raikes, A. 1989. Women's health in East Africa. Soc. Sci. Med. 28(5):447–759. Rinehart, W. 1987. Employment-based family planning programs. Pop. Rept. J. 34:J921–951. Robey, B., S. O. Rutstein, L. Morris, and R. Blackburn. 1992. National Family Planning Surveys: What Women Say. Population Reports, Series M, No. 11. Baltimore, Md.: Johns Hopkins University, Population Information Program. Rogo, K., and J. M. Nyamu. 1989. Legal termination of pregnancy at the Kenyatta National Hospital using prostaglandin F2 in mid-trimester. E. Afr. Med. J. 66(5):333–339. Rogo, K., et al. 1987. Menarche in African secondary school girls in Kenya. E. Afr. Med. J. 64(8):511–515. Rooney, C. 1992. Antenatal Care and Maternal Health: How Effective Is It? Geneva: WHO. Rosenfield, A. 1989. Maternal mortality in developing countries: an ongoing but neglected epidemic. J. Am. Med. Soc. 262(3):376–379. Rosenfield, A., and D. Maine. 1985. Maternal mortality—a neglected tragedy: where is the M in MCH? Lancet 2:83–85. Royston, E., and S. Armstrong, eds. 1989. Preventing Maternal Deaths. Geneva: WHO. Rubin, G., B. McCarthy, J. Shelton, et al. 1981. The risk of childbearing reevaluated. Am. J. Pub. Hlth. 71(7):712–716. Rushwan, H. 1990. Female circumcision. World Health, April–May. Sargent, C. 1977. The integration of the traditional midwife in a national health delivery system Paper presented at the Ford Foundation Regional Family Health Management Workshop at Cotonou, Benin, December 2. Photocopy. Sargent, C. 1982. The implications of role expectations for birth assistance among Bariba women. Soc. Sci. Med. 16:1483–1489. Sargent, C. 1985. Obstetrical choice among urban women in Benin. Soc. Sci. Med. 20(3)287–292. Shaper, A. G., M. S. R. Hutt, and Z. Fejfar. 1974. Cardiovascular Disease in the Tropics. London: British Medical Association. Sherris, J., and G. Fox. 1983. Infertility and Sexually Transmitted Disease: A Public Health Challenge Population Reports, Series L, No. 4. Baltimore, Md.: Johns Hopkins University, Population Information Program. Slack, A. T. 1988. Female circumcision: A critical appraisal. Human Rights Q. 10:437–486. Smith, J. B., N. F. Burton, G. Nelseon, J. A. Fortney, and S. Duale. 1986. Hospital deaths in a high-risk obstetric population: Karawa, Zaire Intl. J. Gynaecol. Obstet. 24:225–234. Smith, J. C., J. M. Hughes, P. S. Pekow, et al. 1984. An assessment of the incidence of maternal mortality. Am. J. Pub. Hlth. 74(8):780–783. Sokal, D., L. Swadogo, and A. Adjibade. 1991. Short stature and cephalopelvic disproportion in Burkina Faso, West Africa. Intl. J. Gynaecol. Obstet. 35:347–350. Stares, A. 1987. Preventing Maternal Deaths. A Report on the International Safe Motherhood Conference, Nairobi, Kenya, February 1987. New York: World Bank, WHO, and UNFPA. Tahzib, F. 1983. Epidemiological determinants of vesico-vaginal fistulas. Br. J. Obstet. Gynaecol. 90:387–391. Tahzib, F. 1989. Searching for the M in MCH. Lancet 2(8666):795. Tanner, J. M. 1962. Growth at Adolescence. London: Blackwell Scientific. Tarimo, E. 1991. Community-based studies in Sub-Saharan Africa: an overview. In Disease and Mortality in Sub-Saharan Africa, R. G. Feachem and D. T. Jamison, eds. New York: Oxford University Press. Thaddeus, S., and D. Maine. 1990. Too Far to Walk. New York: Center for Population and Family Health, School of Public Health, Columbia University. Tietze, C. 1977. Maternal mortality, excluding abortion mortality. World Hlth. Stat. Rpt. 30:312–339. Timaeus, I. M. 1991. Adult mortality: levels, trends, and data sources. In Disease and Mortality in Sub-Saharan Africa, R. G. Feachem and D. T. Jamison, eds. New York: Oxford University Press. Tinker, A., P. Daly, C. Green, H. Saxenian, R. Lakshminarayanan, and K. Gill. 1994. Women's Health and Nutrition: Making a Difference. Washington, D.C.: The World Bank. Toure, B., P. Thonneau, P. Cantrelle, T. M. Barry, T. Ngo-Khac, and E. Papiernick. 1992. Level and causes of maternal mortality in Guinea (West Africa). Intl. J. Gynecol. Obstet. 37:98–95. Toubia, N. 1993. Female Genital Mutilation: A Call for Global Action. New York: Women Ink. Uche, C. 1980. The context of mortality in Nigeria. Paper presented at the International Union for the Scientific Study of Population Seminar on Social Aspects of Mortality and the Length of Life, Fiuggi Terme, Italy, May 13–16 Ujah, I. A. 1991. Sexual activity and attitudes toward contraception among women seeking termination of pregnancy in Zaria, northern Nigeria. Intl. J. Gynaecol. Obstet. 35(1):73–77. Unuigbe, J. A., et al. 1988a. Abortion-related morbidity and mortality in Benin City, Nigeria: 1973–1986. Intl. J. Gynaecol. Obstet. 26(3):435–439. Unuigbe, J. A., A. U. Oronsaye, and A. A. Orhue. 1988b. Preventable factors in abortion-related maternal mortality in Africa: Focus on abortion deaths in Benin City, Nigeria. Trop. J. Obstet. Gynecol. 1 (1 special ed. ser.):36–39. UN (United Nations). 1989. Adolescent Reproductive Behavior: Evidence from Developing Countries, Volume 11, UN Population Studies 109. New York. UNDP (United Nations Development Programme). 1994. Human Development Report. New York: Oxford University Press. U.S. Bureau of the Census. 1995. International Database. Washington, D.C.: U.S. Bureau of the Census, Aging Studies Branch. van Roosmalen, J. 1987. Symphysiotomy as an alternative to cesarean section. Intl. J. Gynaecol. Obstet. 25:451–458. van Steenbergen, W. M., J. A. Kusin, M. Van Rens, et al. 1984. Lactation performance Pp. 153–166 in Maternal and Child Health in Rural Kenya: An Epidemiological Study J. K. van Ginneken and A. S. Muller, eds. London: Croon Helm. Verzin, J. A. 1975. Sequelae of female circumcision. Sudan Med. J. 5:178–212.

OCR for page 80
IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Vis, H. L., and P. Hennart. 1987. Exclusive and partial breastfeeding and infant development in Central Africa. In Weaning: Why, What and When? A. Gallabriga and J. Veny, eds. Nevey, Switzerland: Nestle Nutrition. Walker, A., and P. Parmar. 1993. Warrior Marks: Female Genital Mutilation and the Sexual Blinding of Women. New York: Harcourt Brace. Walsh, J. A., C. M. Feifer, A. R. Measham, and P. J. Gertler. 1993. Maternal and perinatal health. In Disease Control Priorities in Developing Countries, D. T. Jamison, W. H. Mosley, A. R. Measham, and J. L. Bobadilla, eds. New York: Oxford University Press. Wentz, A. C. 1988. Management of menopause. Pp. 397–442 in Novak's Textbook of Gynecology 11th ed., H. W. Jones et al., eds. Baltimore: Williams and Wilkins. White, S. M., et al. 1987. Emergency obstetric surgery performed by nurses in Zaire. Lancet 28:337–342. Whitehead, R. G., M. Hutton, E. Muller, et al. 1978. Factors affecting lactation performance in rural Gambian mothers. Lancet 2(8082):178–181. Winikoff, B., and M. Sullivan. 1987. Assessing the role of family planning in reducing maternal mortality Stud. Fam. Plan. 18(3):128–143. World Bank. 1992. Better Health in Africa. Washington D.C.: World Bank, Africa Technical Department. World Bank. 1993. World Development Report 1993: Investing in Health. New York: Oxford University Press. World Bank. 1994. Better Health in Africa. Washington, D.C.: World Bank. WHO (World Health Organization). 1981. Research in Menopause. WHO Technical Report Series 670:1–120. Geneva. WHO (World Health Organization). 1982. The Prevalence of Anaemia in Women. Geneva. WHO (World Health Organization). 1986. A Traditional Practice that Threatens Health-Female Circumcision. WHO Chronicle 40(1):31–36. WHO (World Health Organization). 1987a. Genital human papilloma virus infections and cancer: memorandum from a WHO meeting. WHO Bull. 65:817–827. WHO (World Health Organization). 1987b. Maternal mortality dimensions of the problem. Paper presented at the Safe Motherhood Conference, Nairobi, February 10–13. WHO (World Health Organization). 1989. The Health of Youth, Facts for Action. Youth and Sexually Transmitted Diseases. A42/Technical Discussions/10. Geneva. WHO (World Health Organization). 1990. Maternal Health and Safe Motherhood Programme Progress Report, 1987 –90. Geneva. WHO (World Health Organization). 1991a. Essential Elements of Obstetric Care at First Referral Level, 1986 WHO Technical Report No. 3328E. Geneva. WHO (World Health Organization). 1991b. Maternal Mortality: A Global Factbook. Geneva. Wrinkrist, A., K. M. Rasmussen, and J. P. Habicht. 1992. A new definition of maternal depletion syndrome. Am. J. Pub. Health 82(5):691–694. Wynn, R. M. 1983. Obstetrics and Gynecology: The Clinical Core, 3rd Ed., Philadelphia: Lea and Febiger. Zimicki, S. 1989. Fertility and maternal mortality. In Contraceptive Use and Controlled Fertility: Health Issues for Women and Children—Background Papers, A. M. Parnell, ed. Washington, D.C.: National Academy Press.