In Her Lifetime Female Morbidity and Mortality in Sub-Saharan Africa (1996) / Chapter Skim
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4 Obstetric Morbidity and Mortality
4 Obstetric Morbidity and Mortality
Pages 80-122
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From page 80... ...
The likelihood that a woman will experience a maternal death is directly 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.
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From page 81... ...
; and three conditions related to female sexual identity (HIV/AIDS, the sequelae of female genital mutilation, and the entire group of sexually transmitted diseases)
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From page 82... ...
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.
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From page 83... ...
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~.
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From page 84... ...
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 SubSaharan African countries (Graham, 1991; Hill and Graham, 19883. 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~.
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From page 85... ...
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 10O,000 live births.
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From page 86... ...
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, 19891. 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~.
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From page 87... ...
SOURCES: Population estimates are from the World Bank, 1992. Maternal mortality ratios are from WHO, 1991 b.
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From page 89... ...
89 ;^ c5-: i~ ° 8 ~ - _ ~ o o o o au ~ .
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From page 90... ...
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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From page 91... ...
Prediction, Prevention, and Cure Prevention is a fundamental principle of public health. Its core strategies are to target high-risk groups and to apply interventions of known effectiveness-routine immunizations, breastfeeding, family planning, nutrition education, and food supplements are classic examples, together with early detection of disease through interview, screening procedures, physical examination, and early intervention.
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From page 92... ...
Of the latter group, the most important for Sub-Saharan African women at present are HIV/AIDS, sexually transmitted diseases and other genital infections, tuberculosis, hepatitis, malaria and other parasitic diseases, iodine deficiency, genetic diseases (sickle-cell anemia, thalassemia) , and certain chronic diseases (some cardiovascular diseases, diabetes, hypertension, renal disease, and cervical cancers)
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From page 93... ...
, so that the risk approach to maternity care may not be the best option for reducing maternal deaths in developing countries. By virtue of the greater representation of "low-risk" and "norisk" women in the female population, more actual cases of obstetric complication occur in these groups in absolute numbers than among women identified as being at high risk (Ekwempu, 1993; Maine, 1991~.
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From page 94... ...
Reviews of maternal deaths often reveal that clinical management of the cases under analysis, even when technically correct, was sadly delayed or delivered by a practitioner with too little experience. Appropriate medical response involves knowing not just what to do and how to do it, but having the resources (drugs, operating rooms, blood supply, and the like)
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From page 95... ...
Although these elements are of unequal importance, the failure of a society to provide any one of them should be considered a contributor to maternal mortality, as well as morbidity. For purposes of this analysis, the multiple causes of maternal death are sorted into three categories: clinical causes, health services issues, and sociocultural factors.
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From page 96... ...
, hemorrhage, obstructed labor, sepsis, ruptured uterus, and unsafe induced abortion. Three-quarters of all maternal deaths can be attributed to hemorrhage, sepsis, or eclampsia (Graham, 19913.
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From page 97... ...
, attention to antisepsis in hospitals and maternity homes, judicious use of antibiotics and fluid support in case of prolonged rupture of membranes, and treatment of anemia to enhance resistance to infection are all solid, low-cost preventive interventions. Obstructed Labor Obstruction occurs when an infant cannot readily pass through the birth canal because of disproportion between its size and the size of its mother's pelvis, because of a pelvic distortion, because of a transverse lie, or because of severe scarring from female genital mutilation (FGM)
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From page 98... ...
The degree to which that mortality and related morbidity can be attributed to harmful traditional practices is almost impossible to measure. A recent study in Nigeria determined that 4 percent of reported maternal deaths were attributable to such practices (WHO, l991b)
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From page 99... ...
A study in Kenya reported rates of upper reproductive tract infections that were approximately 10 times the rates in developed countries; one cause of such infection was the introduction of foreign objects such as leaves, earth, or cow dung into the birth canal by untrained birth attendants for purposes of inducing or hastening labor or halting hemorrhage (Plummer et al., 1987~. Whether pharmaceutical or herbal, the misuse of uterine stimulants has been implicated in deaths from obstructed labor and ruptured uterus, and many of the herbal medicines used to facilitate labor in East and West Africa seem to contain ingredients with definite oxytocic action (Egwuatu, 1986~.
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From page 100... ...
Female Genital Mutilation (FOM) Three types of FGM are practiced: sunna circumcision, which involves removal of the prepuce of the clitoris, with the clitoris itself preserved; excision or clitoridectomy, which involves removal of the prepuce and glans of the clitoris and the labia minora, with no intentional closure of the vulva; and infibulation or "Pharaonic circumcision," which involves removal of the clitoris, labia minora, and at least the anterior two-thirds, and often the entire medial part, of the labia majora, with the vulva sewn shut and a small opening left for urine and menstrual flow.
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From page 101... ...
The result is, at a minimum, discomfort; if the impedance (cryptomenorrhea) is substantial, pain is considerable and the risk of pelvic infection increases, which may lead to infertility (see Chapter 11, Sexually Transmitted Diseases)
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From page 102... ...
Burkina Faso* Cameroon Central African Republic*
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From page 103... ...
The highest maternal mortality rates have been reported from areas that practice female circumcision (Hosken, 1982) , but whether this relationship is causal or coincidental is simply not known, since there is ample latitude for confounding.
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From page 104... ...
but also to the abilities and knowledge of the practitioner, cleanliness of surgical instruments and environment, accessibility of medical facilities, and cultural acceptance of those facilities. Female circumcision may be ostensibly discouraged by authorities, and even be illegal in some regions, so that children and adolescents residing near a hospital often may not be brought in for attention to immediate complications.
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From page 105... ...
or under the bridge of skin that covers the urinary meatus Retention cyst Sebaceous substance composed of fat Cyst can become infected Neuroma Disfiguration of external genitalia and epithelial debris Tumor on the nerve to the clitoris Can cause severe dyspareunia No physical sequelae SOURCES: Tables 4-9 through 4-11 are original constructions using many published sources, including but not limited to: Aziz, 1980; Bakr, 1982; Cook, 1982; Cutner, 1985; Dorkenoo and Elworthy, 1992; E1 Dareer, 1982a,b; Gordon, 1991; Harrison, 1983; Hosken, 1982; Ismail, 1982; Ladjali and Toubia, 1990; Kheir, 1991; McLean and Graham, 1985; Modawi, 1982; Slack, 1988; Tahzib, 1983; Verzin, 1975; Williams, personal communication, 1993; and WHO, 1986. In sum, these traditional procedures produce morbidity in Sub-Saharan African females and may also contribute to their mortality.
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From page 106... ...
Single-purpose clinics are another impediment: a health center may offer a well-baby clinic on two days of the week and antenatal care on the other three days, so that a woman bringing an infant for immunizations must make a separate trip for her own antenatal care. Maternal and child health (MCH)
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From page 107... ...
The Demographic and Health Surveys (DHS J show that African women continue having children even when they do not wish to do so (see Table 4-121. In Burundi, over half of all women respondents noted that they wanted to delay their next pregnancy, and 18 percent wanted no more children, but only 9 percent were currently using family planning.
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From page 108... ...
demonstrate that it is more efficient to tighten the focus of family planning programs to the at-risk groups that are most likely to be receptive. Even though prevention of births among women under 20 years would eliminate 42 percent of maternal deaths (Harrison and Rossiter, 1985)
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From page 109... ...
Immediate childbearing is expected after marriage, and often after an infant death to replace the lost child. Where marriage comes early and infant mortality rates are high, family planning may not be the desired option for many women.
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From page 110... ...
Rogo (Rogo et al., 1987) estimated that 20 percent of all maternal deaths in East and Central Africa were the result of complications of induced abortion.
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From page 111... ...
Although overall duration of breastfeeding is longer in Sub-Saharan Africa than in most of other areas of the world, only in Burundi and Mali are over 50 percent of children under 4 months breastfed exclusively; this suggests that breast milk substitutes, such as water or formula, are introduced very early in most countries (Robey et al., 1992~. Nevertheless, while breastfeeding is good for infant health, the tradeoffs in maternal health may not be as advantageous, particularly in the presence of severe malnutrition and famine.
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From page 112... ...
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 SubSaharan Africa is no exception (see Chapter 3~.
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From page 113... ...
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.
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From page 114... ...
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.
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From page 116... ...
· 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.
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From page 117... ...
1985. Maternal deaths in Washington State.
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From page 118... ...
1987. The importance of family planning in reducing maternal mortality.
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From page 119... ...
1987. Prevention of maternal deaths in developing countries: Program options and practical considerations.
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From page 120... ...
1984. Maternal deaths at King Edward VIII Hospital, Durban.
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From page 121... ...
1989. Preventing Maternal Deaths.
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From page 122... ...
1987. Assessing the role of family planning in reducing, maternal mortality.
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