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In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa (1996)

Chapter: 4 Obstetric Morbidity and Mortality

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Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

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,

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

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.

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
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

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

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

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

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.

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

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

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

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,

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

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.

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

FIGURE 4-1 Maternal mortality in Sub-Saharan Africa. SOURCE: WHO, 1991b.

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

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.

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

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).

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
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THE NATURE OF MATERNAL MORTALITY AS A PUBLIC HEALTH PROBLEM

Maternal mortality is unlike other public health problems in several ways. First, although mortality is an ever-present threat, most women wish to be pregnant and to deliver a child at least once in their lives. Thus, although primary prevention is not entirely relevant, the prevention of unwanted pregnancy is not simply crucial, it is the single most important preventive intervention.

Second, maternal mortality has multiple clinical causes. In this, it is similar to infant mortality and, like infant mortality, it is an event defined by time rather than by cause. But unlike infant mortality, there are no magic bullets—no Expanded Programme of Immunization (EPI) or oral rehydration therapy (ORT)—with which to respond.

Third, cure plays a central role in reducing maternal mortality. Once a woman is pregnant, only a few of the conditions that lead to maternal mortality can be prevented; the actual saving of lives, or cure, is generally dependent on appropriate response.

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. It is uncommon for curative measures to be a focus of public health interventions; oral rehydration therapy in the treatment of childhood diarrhea is a notable exception. For reasons discussed below, strategies that address maternal mortality and morbidity are another—and important —exception.

Prediction: Risk Factors and the Utility of Risk Scores

The risks of maternal mortality and morbidity can be assigned to two major categories: (1) maternal, or "host," characteristics, including age, parity, stature, and underlying or concurrent disease; and (2) community characteristics, primarily location and isolation, whose main effects have to do with the availability and quality of health care. Not all the traditionally accepted risk factors are of equal predictive value, and some of the traditional wisdom that has accumulated around them is questionable; a classic study in Kasongo, Zaire, catalogs some of the difficulties in risk-factor scoring systems for maternal mortality and inspires caution (Kasongo Project Team, 1983). At the same time, there are risk factors that can be useful in identifying women who require special attention. Of course, this does not mean that women with no risk factors will have uncomplicated deliveries.

Maternal Characteristics

Age and Parity Women who are too old, too young, or have had too many pregnancies are at higher risk of obstetric complications; birth interval is an additional and confounding factor (Graham, 1991). The definitions of "old," "young," and "many" are, of course, debated. Regardless of the precise definitions, adolescents (< 16), older women (> 40), primiparae (P = 0), and grandmultiparae (P > 4) are all more likely to experience a complication during pregnancy or delivery, and their infants are more likely to die before, during, or soon after birth. Very young women, whose pelvic bone growth is still not completed, are more likely to have a narrow birth canal, the leading cause of difficult deliveries that prolong labor and increase the risk of obstetric fistulae. Young women and primiparae are more likely to develop hypertension and eclampsia. Both young unmarried women and older mothers with several children are more likely to seek abortions because of unwanted pregnancies.

At the same time, there are subsets of risk where attribution is less clear. For instance, it is widely believed that grandmultiparae are at increased risk of postpartum hemorrhage. Yet a recent analysis of 9,598 vaginal births in the United States (3.9 percent of which involved a postpartum hemorrhage) found that risk of hemorrhage was

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
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TABLE 4-3 The Value of Height as a Predictor of Cesarean Section (CS) for Cephalopelvic Disproportion (CPD), Ouagadougou, Burkina Faso (percent)

Height (cm)

At Each Cut-off Point CS for CPD

Sensitivity

Specificity

< 150

48.8 (2/41)

8

98

150–154

46.7 (10/214)

46

86

155–159

17.2 (8/466)

77

59

160–164

10.8 (6/553)

100

26

165–169

0 (0/342)

170+

0(0/98)

NOTE: Sensitivity is defined as the percentage of women with a problem (CS for CPD) who were identified as high-risk (2/26 = 8 percent at 150 centimeters; 12/26 = 46 percent at 155 centimeters). Specificity is defined as the percentage identified as low-risk who had no problem (no CS for CPD [1,649/1,673 = 98 percent at 150 centimeters; 1,459/1,688 = 86 percent at 155 centimeters]).

SOURCE: Adapted from Sokal et al., 1991.

not correlated with greater parity. The most robust risk factor in this study was primiparity per se; preeclampsia was also (independently) strongly associated with hemorrhage (Combs et al., 1991). The vast majority of primiparae deliver safely, and the proportion of postpartum hemorrhages that occur to primiparae will depend simply on the proportion of births to women having their first births, a proportion that is lower in Africa than elsewhere in the world because absolute parity in the region is so high.

Stature In general, very short women are more likely to have obstructed labors; as a group they can thus be expected to account for more cesarean sections (CS) (Sokal et al., 1991; see Table 4-3), both because they require them and because there is some predilection among physicians to section small women as a matter of course.

There are some methodologic questions about maternal height as a predictor for obstructed labor. Although the measure is commonly utilized as a risk factor for that obstetric event, most often with a maternal height of 150 cm used as the critical cutoff point, Table 4-3 suggests that it is a poor measure. Of 26 women who had a cesarean section for cephalopelvic disproportion (CPD), only 8 percent would have been correctly predicted with a cutoff of 150 cm; that figure rises to 46 percent if the cutoff is raised to 155 cm. Looked at another way, of women defined as "at risk"—that is, under 150 cm in height—95 percent did not have a cesarean section. As a consequence, the study authors (Sokal et al., 1991) recommend a 155-cm cutoff as a more sensitive and specific predictor. It is important to call attention to the risks of drawing conclusions from such a small sample; this is a point of general relevance for health policy recommendations in Sub-Saharan Africa, because there are still so few studies of the size and scientific rigor required to permit comfortable inferences (W. Graham, personal communication, 1994)

Underlying, Latent, and Concurrent Disease A number of conditions and health events can coincide with pregnancy and childbirth and conspire to elevate the degree of risk to fetus, mother, and infant. These can be divided into: (1) those that do not affect pregnancy and are not exacerbated by it and (2) those that either affect or are affected by pregnancy and delivery. 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). The majority of these are addressed in detail in the relevant chapters of this report. Women with any of these conditions require special vigilance during pregnancy and delivery, although an appropriate course of management is not always available. They must all be considered as possible clinical causes in the multiple causality of

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
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maternal death, which is taken up below. That African women continue heavy work late into pregnancy further compounds these risks (Feachem et al., 1989; Raikes, 1989).

Community Characteristics

Women who live in communities far from health facilities are not only more likely to experience complications of pregnancy and delivery, but are also less likely to receive adequate treatment for those complications (Thaddeus and Maine, 1990). They are also at risk if they live in communities that are isolated for other reasons—such as weather that makes roads impassable in the rainy season or geographic factors such as water barriers—risk that is compounded in remote or isolated villages that lack telecommunications, as most do. Finally, women and their communities can be isolated for cultural reasons: nomads, refugees, and members of particular religious or ethnic groups are notable examples. Women who are directly isolated by culturally rooted seclusion, or purdah, or indirectly by illiteracy or age, may also be less likely to receive adequate care during pregnancy and delivery. It is absolutely crucial to keep in mind that the usual co-variates of remoteness in Sub-Saharan Africa are poverty, poor nutritional status and short stature, and illiteracy, which have their own strong and independent influence on all aspects of the reproductive process.

It was for these reasons that a seminal multidisciplinary review (Thaddeus and Maine, 1990) was keyed to the "three phases of delay" that block the effective treatment of an obstetric complication in many developing countries: (1) delay in the decision to seek care (lack of information about complications, lack of women's autonomy), (2) delay in reaching appropriate care (bad roads, no affordable transportation), and (3) delay in the provision of adequate care (shortages of qualified staff, clinical mismanagement, lack of essential drugs and supplies, and the like). The "three delays" provided the theoretical and structural underpinnings of the Prevention of Maternal Mortality Network, which has been established as a major component of the Safe Motherhood Initiative (Carnegie Corporation, 1993). This focus does not in any way imply a disregard for the very fundamental problems of large numbers of early teenage primigravidae, high parity, and lack of antenatal care (Harrison and Rossiter, 1985).

Calculations of Risk

High-risk pregnancies are usually defined as those occurring before age 18 and after age 35, those among women with more than four births, and those less than two years apart (Herz and Measham, 1987; Royston and Armstrong, 1989).

The use of a risk-scoring system has intuitive appeal, and many physicians instinctively do their own informal calculations. A formal risk-scoring system assigns a score to each risk factor and then totals them to get a combined risk score; women with multiple risk factors obviously get higher scores. Such approaches can be helpful, but all systems developed so far have a large number of false positives (women with high scores who have uncomplicated deliveries), false negatives (women with low scores who experience a complication), poor sensitivity (women with complications who received a low score), and poor specificity (women with no complication who received a high score). Furthermore, in some populations nearly all women have at least one risk factor (Fortney and Whitehorne, 1982). Although there are indubitable risk factors for maternal mortality and morbidity, applying them rigidly to predict those events and conditions has its own hazards, the most important among them the sense of false security concerning women with low scores. Overall, previous obstetric history is probably the most valuable predictor of obstetric difficulties in a current pregnancy. It is useless for application to the prospects for primiparae, however, since they have no history to call upon. In sum, a major challenge in achieving "safe motherhood" is the great difficulty of predicting which women will develop complications based on easily measurable characteristics. With few exceptions, it is hard to identify "proneness" to obstetric complications (W. Graham, personal communication, 1994), 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 ''no-risk" 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).

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
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TABLE 4-4 A Paradigm for Prevention of Maternal Mortality

Condition

Before Pregnancy

During Pregnancy

During Delivery

Response Only

Postpartum hemorrhage

No

Yes; raising hemoglobin to enhance tolerance of blood loss prevents some deaths.

Yes; active management of 3rd stage of labor prevents some postpartum hemorrhage

Blood transfusion, oxytocics

Obstruction

Yes; adequate nutrition in childhood and adolescence prevents some obstruction. Delaying pregnancy until full growth is attained will have a comparable effect.

No

Yes; use of partogram

Prompt cesarean section if appropriate

 

No

     

Eclampsia

No

Yes; monitoring blood pressure

Yes; monitoring blood pressure

Drug therapy, bed rest

Sepsis

No

No; except possibly reducing anemia

Yes, clean delivery technique

Antibiotics

Abortion

Yes; access to family planning

No

No

Appropriate management of complications

Prevention

As suggested by the discussion of the risk approach, application of the term "prevention" to maternal mortality and morbidity is ambiguous. The most common clinical causes of maternal death—hemorrhage, obstructed labor, eclampsia, sepsis, and abortion—cannot be prevented in the strict, proximate sense of the term, because so many of these problems are rooted in conditions and events beginning with the mother's own conception. At the same time, mortality and prolonged morbidity from virtually all those causes can be prevented by appropriate and timely medical response. Table 4-4 presents a paradigm for the "prevention" of maternal mortality that displays the spectrum of possibilities for intervention across the female life span.

Cure

The appropriate medical responses to the complications of pregnancy have, for the most part, been known for decades. In the developed world, maternal mortality from hemorrhage and sepsis declined dramatically in the 1940s and 1950s, when cross-matching of blood became possible and the sulfa drugs and antibiotics were developed. Mortality from obstructed labor had declined still earlier, when surgical skills for cesarean section improved and anesthetic techniques were refined. There was no comparable breakthrough in reducing mortality from eclampsia, although case-fatality rates started to decline in the 1950s as sedatives came into use in the clinical management of the condition. Mortality from complications of abortion was also reduced through blood transfusion and antibiotics. None of these medical responses is especially "high tech," and all should be within the skills of general physicians (and some nonphysicians) with basic surgical skills.

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) to respond, having the suitable personnel, and responding soon enough. These

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
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issues are addressed below in the context of health services as crucial variables in the multiple causality of maternal death, and deficits in these areas belong at the top of the list of factors that should be considered "avoidable."

THE MULTIPLE CAUSALITY OF MATERNAL DEATH

At the 1987 Safe Motherhood Conference in Nairobi, Kenya, Professor Mahmoud Fathalla described the death of "Mrs. X" (Fathalla, 1987; see Box 4-1). Clinical cause of death was hypovolemia from antepartum hemorrhage, but there were eight other nonclinical contributing factors. The cardinal point of this landmark presentation was that the probability of "safe motherhood" is enhanced by healthy, literate women having wanted pregnancies; focused and effective prenatal care; accessible, affordable, and appropriate attention for normal deliveries and obstetric emergencies; and physicians and other health care providers who are suitably trained and have adequate access to necessary drugs and services. 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. These obviously overlap, but there is utility in considering them separately.

Clinical Causes

Distinguishing among individual causes for diagnostic and reporting purposes is not straightforward. Immediate and underlying causes may be confused—for example, cardiac failure and toxic shock. Different data sources are more likely to reveal some causes rather than others. For example, hemorrhage may be recorded either as hemorrhage or as retained placenta. Hospital reports are more likely to be deficient in recording deaths of a sudden nature, such as a massive postpartum hemorrhage, compared with deaths from causes with a less rapid progression, such as sepsis. Complications from induced abortion may be coded as such, or without any reference to abortion. Indirect causes of maternal mortality such as pneumonia, tuberculosis, cerebral malaria, and diarrheal diseases may be completely masked under some category called "Other" (Graham, 1991).

BOX 4-1 Why Did Mrs. X Die?

  • Hypovolemia, due to antepartum hemorrhage.

  • Lack of blood for transfusion.

  • Delay in seeking treatment. Failure to recognize significance of antenatal bleeding.

  • Anemia due to parasites and poor diet.

  • No antenatal care which might have recognized significance of bleeding, and treated the anemia and the parasites.

  • High age and parity (Mrs X was 39 and had 7 babies). She wanted no more children.

  • No access to family planning.

  • Mrs X lived in a remote village with no access to transportation.

  • Mrs X was illiterate and poor.

SOURCE: Fathalla, 1987.

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
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Anemia

The World Health Organization has estimated that 52 percent of pregnant women in Africa—56 percent in West Africa, 47 percent in Central Africa, and 54 percent in Middle Africa—have substandard hemoglobin levels (below 100g/L) (WHO, 1982). Severe anemia can contribute to maternal mortality by impairing a woman's ability to resist infection or to survive hemorrhage. A hospital-based study of maternal deaths in Malawi estimated that anemia contributed to 23 percent of those deaths (Keller, 1987). Very young mothers present a special situation: pregnant adolescents (< age 16) in Nigeria who received iron and folic acid supplements and antimalarials grew as much as 16 centimeters during pregnancy, thereby reducing their risk of obstructed births (Harrison et al., 1985a). Parasitic infestations also contribute to anemia; of the parasitic infestations, malaria seems to produce the most egregious insults; in females of reproductive age, mean hemoglobin values tend to be consistently lower in the presence of parasitemia, an association most marked in primiparas (McGregor, 1991; see also Chapter 10). Unfortunately, many of the currently preferred antiparasitic therapies, primarily those in the benzimidazole group, are counterindicated during pregnancy because of their presumed teratogenic effects.

Complications of Pregnancy and Delivery

The most common clinical causes of maternal death and chronic morbidity during pregnancy and delivery are anemia, eclampsia (convulsions resulting from hypertensive disease during pregnancy), 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, 1991). Conditions that can constitute an obstetric emergency include ectopic pregnancy, anesthetic accidents, embolisms from blood clots or amniotic fluid that may result from oxytocin induction, trauma, or medical emergencies associated with such underlying conditions as those discussed earlier.

Hemorrhage and Retained Placenta Bleeding during pregnancy may indicate several conditions, including, in early pregnancy, threatened abortion. Later in pregnancy, it suggests problems in placentation; ideally, women who bleed should receive careful follow-up and deliver in a facility with an operating room. Because bleeding is an easily recognized condition, it is, in principle, more likely to receive medical attention than less apparent conditions. Nonetheless, its significance is often underestimated by pregnant women, and even by many health care providers. The gravity of postpartum hemorrhage can be difficult to define: "excessive" bleeding is a subjective assessment and actual blood loss is rarely accurately measured. Yet in anemic women, even a small amount of blood loss is poorly tolerated.

Retained placenta is defined as a placenta, or placental part, that is not delivered within two hours after delivery of the infant. It has several possible causes, including uterine atony, anomalies of placentation such as placenta accreta, or even a full bladder. Retained placenta or too rapid separation of the placenta (for example, by pulling too hard on the cord) may also cause uterine bleeding.

Interventions to prevent postpartum hemorrhage include careful management of the third stage of labor—that is, appropriate delivery of the placenta—and maintaining an empty bladder. Interventions to treat postpartum hemorrhage include use of oxytocins after delivery of the infant, nipple stimulation after delivery (although this practice is controversial), massage of the uterus, bimanual pressure, packing (also controversial and a last resort), and transfusion of whole blood or other fluids. Occasionally, hysterectomy is necessary.

Postpartum hemorrhage is one of the most common reasons for blood transfusion, an intervention that may be overused in some settings and, since the advent of AIDS, bears additional risks. Although postpartum hemorrhage is potentially fatal, women who survive it rarely suffer long-term consequences.

Sepsis Infection can occur when aseptic procedures are not followed, when the amniotic sac ruptures long before delivery occurs, when vaginal examinations are too frequent, or when prolonged or obstructed labor occurs. Long-term consequences of puerperal sepsis include pelvic inflammatory disease (PID), secondary infertility, and, although uncommon, maternal tetanus.

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
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Infection is the most preventable of the obstetric emergencies. Training of traditional birth attendants in "the three cleans" (clean hands, clean surface for delivery, clean cord care), 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). Unattended, obstruction characteristically leads to prolonged labor (variously defined as more than 18 or more than 24 hours), and sometimes to rupture of the uterus. Obstructed labor can also result in other complications, including necrosing of tissue in the vagina or uterus that can lead to death or, at a minimum, produce highly burdensome morbidity, including secondary infertility or obstruction in subsequent births. Obstruction can also increase the risk of obstetric fistulae, a tearing of the walls between the vagina and bladder or rectum. Women with unrepaired fistulae constantly drip urine or feces and may frequently be ostracized by both their husbands and the community (Tahzib, 1983). Often, such women are quite young: in Nigeria, 33 percent of fistulae cases involved women under age 16; in Niger, 80 percent were between the ages of 15 and 19.

No other complication of delivery is associated with as much chronic morbidity as obstructed labor. While it cannot be prevented, its most severe consequences can be avoided or attenuated by intervention. Use of the partogram during labor leads to early detection of problems, permitting timely intervention, generally cesarean section. While symphysiotomy has some advocates, its use remains controversial (van Roosmalen, 1987). Operative delivery usually requires antibiotics, rehydration, and blood transfusion or plasma expanders.

Hypertensive Disorders Hypertensive disease of pregnancy appears to be most common among primigravidas. The pattern of increased risk for younger primigravidas, below age 20, may be less a reflection of increased physiologic risk than of other differences between this group and women who have their first child at ages 20 to 24 (Zimicki, 1989). These are the most difficult of the obstetric emergencies to prevent and manage, as well as the least understood, yet they are an important cause of maternal death in many areas of Africa. Prevention includes monitoring blood pressure during pregnancy and watching for edema, especially of the hands and face. Clinical trials are underway to determine whether daily administration of low-dose aspirin reduces the incidence of preeclamptic toxemia and eclampsia. Unfortunately for predictive purposes, not all episodes of eclampsia are preceded by preeclamptic toxemia, or even by hypertension.

Treatment of eclampsia includes rapid delivery of the infant, by cesarean section if necessary, and administration of either magnesium sulfate or diazepam. While diazepam is widely available, magnesium sulfate is rarely available below the level of tertiary hospitals. Although eclampsia is potentially fatal, women who recover usually suffer no long-lasting effects, although hypertension may prove persistent.

Abortion The emergencies associated with the complications of clandestine abortion are the same as those related to delivery: that is, infection and bleeding. Treatment is therefore similar. More serious complications can be avoided by prompt aspiration of the uterus to remove remaining products of conception. This can be done in many health centers if staff are appropriately trained and equipment is available. Primary prevention through family planning is preferred.

Response Times The most common obstetric complications vary in their demands for speed. Maine and colleagues (1987) have estimated the average interval from onset to death for the major obstetric complications, absent medical intervention (Table 4-5).

Sociocultural Factors: Traditional Medical Practices

There is a large body of traditional medical practice in Sub-Saharan Africa that is highly pertinent to obstetric

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

TABLE 4-5 Estimated Average Interval from Onset to Death

Complication

Hours

Days

Hemorrhage: postpartum

2

 

Hemorrhage: antepartum

12

 

Ruptured uterus

 

1

Eclampsia

 

2

Obstructed labor

 

3

Infection

 

6

SOURCE: Maine et al., 1987.

mortality and morbidity, either because of the positive contributions those practices make to female health, or because they may be deleterious. These comprise the traditional management of pregnancy, labor, and delivery, customarily a responsibility of traditional birth attendants (TBAs); food prescriptions and proscriptions associated with the pre- and postpartum periods of a woman's life, which are addressed in Chapter 3; and the traditional procedures that have been customarily termed "female circumcision," but are increasingly referred to as "female genital mutilation." This latter group is discussed, from different perspectives, in this chapter and in Chapter 2.

Of all geographic regions, Africa has the lowest percentage of births attended by trained personnel (Starrs, 1987) and the highest maternal mortality rates (Walsh et al., 1993). 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, 1991b). The authors' view, however, is that such attributions are highly tenuous, and that it is more useful to look at what is known about the practices in themselves, and to ask which among them are objectively harmful. It is equally important to be clear about what practices are beneficial, so that those can be encouraged and preserved.

The Traditional Birth Attendant

Throughout the developing world, there is a large arsenal of customary behavior employed to deal with the period from pregnancy through the puerperium. The prime custodian of this arsenal is the TBA, who dominates the obstetric and gynecologic picture in Sub-Saharan Africa. TBAs cover 40 percent of deliveries in Lesotho, 45 percent in Malawi, 50 percent in Swaziland, 60 percent in Tanzania, 70 percent in Zimbabwe, and 77 percent in Botswana (Kaiser Family Foundation, 1993). Their numbers appear to be declining in some areas; in Tanzania, for example, the midwife/live-birth ratio has declined by 50 percent in the last ten years (Kwast, 1991).

Generally a highly esteemed, local older woman, the TBA is considered an authority on the traditional medical practices associated with childbearing, as well as child-rearing, traditional methods of family planning, and the treatment of infertility. Birth attendants or other traditional healers are from the community, speak the local language, charge modest fees or accept payment in kind, and, patients insist, can handle the common exertions of childbirth. Equally important, they provide strong emotional support during and following labor. Thus, in some African countries, such as Ghana, TBAs, already highly regarded by local populations, have been given medical and paramedical training and have proven to be valuable adjuncts to the government health care system and to other community and traditional practitioners. Success is not inevitable: in Nigeria, relationships between TBAs and untrained traditional midwives were strained enough to require remedial attention (Okafor, 1991). It is also possible that the indigenous setting does not offer a solid basis for such training: in some ethnic groups, women are expected to experience labor in stoic solitude, and the birth attendant is called in only to cut the umbilical cord, wash the baby, and ritually bury the placenta.

The initial focus of many TBA training programs worldwide has been on practices that are important to the well-being of the neonate, primarily prevention of tetanus and ocular hygiene. The second area of training deals

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

with practices related to potentially life-threatening situations for the mother: hemorrhage, obstructed labor, and maternal sepsis.

Treatment of hemorrhage relies on locally available herbal medicines; while these may not in themselves do harm, the delay involved before more appropriate care can be reached may prove fatal. Somewhat analogous is utilization of oxytocin-containing medicines and equivalent substances, often ergot derivatives, to induce or accelerate labor (Zimicki, 1989). These are available in pharmacies or in traditional forms and can be beneficial in the postpartum period for restoring uterine tonus. At the same time, because they produce quick, strong, and sustained contractions, they can produce uterine rupture when employed during labor itself. When oxytocins in herbal form are inserted directly into the vagina, there is a high-risk of intrauterine infection and tetanus. 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).

Another source of infection cited in the same study was the entry of germs into the genital tract by use of unsterilized instruments and by insertion of unwashed hands during vaginal examination by the untrained midwife, usually to ascertain the degree of cervical dilation. A TBA must also confront such emergency situations as fetal malpresentation. An understandable but regrettable response is vaginal manipulation, forcible internal version of the fetus, and vigorous handling of the parturient herself, all behaviors with high-risks of infection, excessive blood loss, or both (Beddada, 1982; Modawi, 1982). Expulsion of the placenta, particularly in the case of retained placenta, may evoke such forcible and deleterious interventions as pulling the umbilical cord out, reaching into the birth canal to extract it, or forcing a gagging reflex (Otoo, 1973), rather than relying on natural contractions or gentle abdominal massage to effect expulsion. The longer and more difficult the labor, the more likely it is that a TBA will resort to extreme measures, the longer those may last, and the higher the risks.

As is the case in recent evaluations of the impact of training community health workers (CHW) on community health status, assessment of the effectiveness of TBAs has been largely focused on their effect on child survival, because TBA training has placed considerable emphasis on such relevant practices as antisepsis to prevent neonatal tetanus through anti-tetanus immunization and hygienic management of the umbilicus. In these respects, TBA training programs in Burkina Faso, Liberia, Malawi, Mozambique, Senegal, Sierra Leone, and Zaire have produced real decreases in neonatal mortality attributable to tetanus (Ewbank, 1993). In The Gambia, however, a mortality survey to assess the impact of a TBA program on maternal mortality showed no effect (Knippenberg et al., 1990), although, as suggested at the outset of this chapter, the relative infrequency of maternal deaths is a problem for any evaluative exercise.

The value of TBAs to their communities in general, and to women in particular, could be substantial; an especially useful and supportive body of evidence for this effect is the comprehensive ethnographic work of Sargent in Benin (Sargent, 1977, 1982, 1985). When access to nondomiciliary birthing facilities is severely limited, as it is in much of Sub-Saharan Africa, having someone who is experienced and nearby is, in itself, highly positive. The traditional practices of massage, motivation for breastfeeding, and an attitude of support for the parturient are absolutely desirable. In Ghana, the general sense is that even when good-quality maternity care is accessible, by custom women prefer to deliver at home, assisted by a traditional midwife or relative (Carnegie Corporation, 1993).

Trained for appropriate management of pregnancy and perinatal risk, for recognition of warning signs, and stabilization and referral as appropriate, the traditional midwife has the potential to be a crucial ally in resource-constrained environments. At the same time, there is ample evidence that where there has been no clearly mandated and well-defined connection to an existing health system, where supervision and support have been inconsistent, and where necessary logistical support has failed, the involvement of community workers, including TBAs, in health care delivery inevitably crumbles (Herz and Measham, 1987; World Bank, 1994).

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×
Gishiri Cuts

The Gishiri cut is a traditional procedure among the Hausa in northern Nigeria in which the vagina is cut, usually by a traditional healer, typically an older woman, for the purpose of treating a number of gynecologic and obstetric conditions (Harrison and Rossiter, 1985). These include amenorrhea, urinary dysfunction (dysuria), backache, infertility, painful intercourse (dyspareunia), and prolonged labor. The intervention consists of cuts in the anterior and, sometimes, posterior area of the vagina. Hemorrhage, reproductive tract infections, and vesico-vaginal fistula are common complications. Tahzib (1983) found that 13 percent of all fistula diagnoses in his sample of 1,443 women were directly attributable to gishiri cuts, particularly in older females. It is sometimes the case that gishiri incisions are superficial, and therefore less potentially deleterious, but the percentages of cases, where, and under what circumstances this more superficial intervention occurs are completely unknown. There also appears to be little systematic knowledge of how extensively the practice is employed by TBAs during childbirth as a form of episiotomy.

Female Genital Mutilation (FGM)

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. The differences among the types of intervention reside in the extent of the procedure and the portions of the genitalia excised (see Table 4-6).

The intervention is practiced in some form, with varying prevalence, in a band that crosses Sub-Saharan Africa north of the equator, in a total of 26 Sub-Saharan African countries with an "affected population" of 114,296,900 (Table 4-7) (Toubia, 1993). Prevalence of each procedure varies not only geographically but, to some degree, by level of education (see Table 4-8). In a sample of over 3,000 women and 1,500 men, a major study in northern Sudan between 1977 and 1981 found level of education to be a powerful predictor: 75 percent of infibulated women were from illiterate families (El Dareer, 1982b), which suggests that they were also from poor families (World Bank, 1993). At the same time, the practice is not limited to females from the lower socioeconomic strata: for example, government-trained TBAs and nurse-midwives in northern Sudan are reported to provide the service to elite, educated women (Kheir et al., 1991).

The Procedure Most excisions are performed by TBAs, trained midwives, or men and women identified within a group as having special skills, notably heads of secret societies (Lightfoot-Klein, 1989). The practice generally enhances the income of the practitioner, which some commentators (e.g., Hosken, 1982) perceive as an important

TABLE 4-6 Types of Female Circumcision

Type of Surgery

Description

Sunna circumcision (Type I)

Removal of the prepuce of the clitoris, while the clitoris itself is preserved.

Recovery is approximately 7 days.

Excision (Type II)

Removal of prepuce and glans of the clitoris, and part or all of the labia minora.

No (intended) closure of the vulva. Recovery is between 7 and 15 days.

Infibulation (Type III)

Removal of the clitoris, labia minora, and at least the anterior two-thirds and often the entire medial part of the labia majora. The vulva is sewn shut, leaving a small opening for urine and menstrual flow. Recovery is approximately 40 days.

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

consideration in its maintenance. Razor blades, scissors, kitchen knives, or sharp pieces of glass are among the tools used; in parts of Sierra Leone and a number of other countries, surgical scalpels are now in use. No general anesthetic is administered in most cases; local anesthesia may be administered and various indigenous herbs and medicines employed to stop bleeding and promote healing (Kheir et al., 1991). Antibiotics and tetanus toxoid are frequently unavailable. In urban areas, particularly among the elite, the procedure is likely to be performed by trained nursing persons or physicians in clinic or hospital settings under sterile conditions, suturing is done with catgut or silk, and anesthesia and antibiotics are used (Gordon, 1991).

Age at Time of Procedure The age range of child and adolescent genital excision varies from a few days after birth into adulthood. In Sudan, it is performed at age 10, before puberty (Kheir, 1991); in most countries of West Africa, it is usually performed on adolescents between 11 and 15 years, less frequently at ages 5 to 6. In some areas it had not been uncommon in the past for the procedure to be performed directly prior to the marriage ceremony, but there now seems to be a tendency to perform the procedure at earlier ages (Lightfoot-Klein, 1989; Slack, 1988). Younger girls can be more easily restrained, so that excision tends to be more precise, and there is some feeling that the intervention is less traumatic for younger girls because their genitalia are less developed (Koso-Thomas, 1985).

Like circumcision for Sub-Saharan African males, FGM for females in many African societies is viewed as a rite of passage—that is, it marks movement from one major life stage to another—and is characteristically managed by secret societies. This explains some of the attitudinal context for the practice, and perhaps at least some of its persistence and prevalence.

Complications and Sequelae Because even the most minimal forms of FGM are invasive, complications are frequent. Since so many of these complications can become chronic, they are usefully categorized by duration—immediate and long-term —and by their obstetric implications (Tables 4-9 and 4-10). The sequelae of infibulation are the most serious. For example, pelvic inflammatory diseases (PID) are three times more common in women who have been infibulated than in those who have not (Cook, 1982). In turn, recurrent PIDs are identified as one of the major causes of high infertility, even when antibiotic therapies are available; this is a very consequential side-effect in societies that place a high value on fecundity.

Immediate complications range from injury to adjacent structures, such as the urethra and anus, to severe hemorrhage and shock. There may also be acute site infection, beginning a recurring cycle of infection, and even minor infections can prove fatal in the absence of antibiotics. The practice of infibulation requires that the patient's legs be tied together from thighs to ankles to permit healing, but drainage is also impaired even with light bandaging, and the spread of infection into vagina and uterus is promoted (Verzin 1975, in Cook, 1982).

Long-term complications begin for girls when the passage of menstrual flow is impeded at the onset of menarche. 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). Attempts at penetration upon first intercourse may be effected through use of a knife or other sharp object; sepsis leading to PID is possible, and severe pain would seem to be inevitable. In the case of the sunna procedure, complete penetration requires three to seven days; if the woman has been excised, two to five weeks are required; and, after infibulation, complete penetration can take between two and twelve weeks to be effected (El Dareer, 1982b). Forcible penetration can cause development of a "false vagina" or lacerations of the perineum, rectum, and urethra. Long-term dyspareunia (painful intercourse) is common, and the sequelae of that condition may not only be felt physiologically, but also in interpersonal relations between spouses.

The very limited research into the effects of FGM on sexual arousal is inconclusive. Because the operation destroys sensitive nerve endings in the clitoris and labia minora, leaving only scar tissue, sexual arousal in excised women can be impaired or delayed (Bakr, 1982). Nevertheless, available published research is limited and contradictory. In a study of Nigerian women, Megafu (1983) found that the sexual urge in her sample was not impaired by removal of the clitoris; Koso-Thomas (1985) found that excised women were less likely to experience orgasm than unexcised women. El Dareer (1982b) reports that 75 percent of the women in her survey sample of 3,210 never experienced sexual pleasure or were indifferent.

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

TABLE 4-7 Female Genital Mutilation in Africaa

Country

Prevalence (%)

Actual Number

Notes

Benin*

50

1,200,000

 

Burkina Faso*

70

3,290,000

 

Cameroon*

Information on prevalence not available.

Central African Republic*

50

750,000

 

Chad

60

1,530,000

Prevalence based upon 1990 and 1991 studies in three regions.

Côte d'Ivoire*

60

3,750,000

 

Djibouti

98

196,000

Infibulation almost universally practiced. The Union Nationale des Femmes de Djibouti (UNFD) runs a clinic where a milder form of infibulation is performed under local anesthesia.

Egypt

50

13,625,000

Practiced throughout the country by both Muslims and Christians. Infibulation reported in areas of south Egypt closer to Sudan.

Ethiopia and Eritrea

90

23,940,000

Common among Muslims and Christians and practiced by Ethiopian Jews (Falashas), most of whom now live in Israel. Clitoridectomy is more common, except in areas bordering Sudan and Somalia, where infibulation seems to have spread.

Gambia*

60

270,000

 

Ghana

30

2,325,000

A 1987 pilot survey in one community showed that 97% of interviewed women above age 47 were circumcised, while 48% of those under 20 were not.

Guinea*

50

1,875,000

 

Guinea Bissau*

50

250,000

 

Kenya

50

6,300,000

Decreasing in urban areas, but remains strong in rural areas, primarily around the Rift Valley. 1992 studies in four regions found that the age for circumcision ranged from eight to 13 years, and traditional practitioners usually operated on a group of girls at one time without much cleaning of the knife between procedures.

Liberia*

60

810,000

 

Mali*

75

3,112,500

 

Mauritania*

25

262,500

 

Niger*

20

800,000

 

Nigeria

50

30,625,000

Two national studies conducted, but not released. A study of Bendel state reported widespread clitoridectomy among all ethnic groups, including Christians, Muslims, and animists.

Senegal

20

750,000

Predominantly in the north and southeast. Only a minority of Muslims, who constitute 95% of the population, practice FGM.

Sierra Leone

90

1,935,000

All ethnic groups practice FGM except for Christian Krios in the western region and in the capital, Freetown.

Somalia

98

3,773,000

FGM is universal; approximately 80% of the operations are infibulation.

Sudan (North)

89

9,220,400

A very high prevalence, predominantly infibulation, throughout most of the northern, eastern and western regions. Along with a small overall decline in the 1980s, there is a clear shift from infibulation to clitoridectomy.

Tanzania

10

1,345,000

Clitoridectomy reported only among the Chagga groups near Mount Kilimanjaro.

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

Country

Prevalence (%)

Actual Number

Notes

Togo*

Uganda*

Zaire*

Total

50

5

5

950,000

467,500

945,000

114,296,900

 

*Anecdotal information only; no published studies.

a Estimated prevalence rates have been developed from reviews of national surveys, small studies, and country reports and from F. Hosken, WIN News 18(4), Autumn 1992.

SOURCE: Toubia, 1993.

TABLE 4-8 Type of Female Circumcision, by Country, Sub-Saharan Africa

Type of Surgery

Country

Sunna circumcision and excision

Benin, Burkina Faso, Central African Republic, Chad, Djibouti, Ghana, Côte d'Ivoire, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, Sudan, Tanzania, Togo

Infibulation

Central African Republic, Djibouti, Eritrea, Ethiopia, Kenya, Mali, Nigeria, Somalia, Sudan

Unknown (or published information unavailable)

The Gambia, Guinea, Guinea Bissau, Uganda, Zaire

Recently, the possibility that the most extreme surgical forms produce limits on overall physical agility has been raised (Walker and Parmar, 1993). This is not implausible, but it is contemplated in a fictional context that, while compelling, can only suggest a direction for more systematic investigation.

A natural expectation is that obstetric complications would be almost inevitable for women who have been infibulated (Table 4-11). Anterior episiotomy is generally an essential part of childbirth for these women; where this is effected with unsterile instruments, not only is infection probable, but scar formation is enhanced. In each successive birth, then, the small size of the residual vaginal aperture continues to be a problem, one that is exacerbated by the inflexibility of accumulated scar tissue. Vesico-vaginal and recto-vaginal fistulae, which produce their own sequelae as noted earlier in this chapter, are common.

Reinfibulation Following delivery, it is not uncommon for the vulva to be resutured and reinfibulated (Hosken, 1982). El Dareer (1982b) found that 80 percent of her sample of 3,210 married women had been reinfibulated following delivery, citing ''custom" as their rationale. Husbands who pay for the additional surgery may be considered as lending at least tacit approval. There are also cases of widows, divorced women, and married women requesting reinfibulation (El Dareer, 1982b).

Mortality and Morbidity The discussion has so far emphasized morbidity. There is also cause to suspect some burden of mortality deriving from FGM sequelae (Tables 4-3 and 4-4), but its dimensions are unknown. 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. Degrees of morbidity and occurrence of fatality not only relate to the extent of the intervention itself,

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

TABLE 4-9 Immediate Complications and Sequelae of Female Circumcision

Complication

Description

Sequelae

Hemorrhage

Severe bleeding resulting from severing of the dorsal artery of the clitoris, or from the labial branches of the pudendal artery

Anemia; shock; possible death

Trauma to adjacent structures

Particularly to the urethra, urinary meatus, vaginal opening, or anus; in extreme cases, the entire urinary meatus is excised

Damage to the urethra can lead to permanent incontinence; acute and chronic urinary retention; damage to the vaginal walls can lead to total occlusion of the vaginal opening

Acute urinary retention

Can occur if the urethra is covered with a flap of skin and dried blood, sometimes requiring reopening

Urinary tract infection(s)

Acute site infection

Infection at excision site

Infection can spread upward into the vagina and uterus, contributing to infertility; lack of antibiotics can lead to death

Tetanus

An infection that releases tetanus toxoid which causes severe and painful muscle spasms

Tetanic convulsions, usually fatal

Septicemia

Blood infection

Hypotension, vascular collapse, renal failure, death

Behavioral disturbances

Irritability, disturbed sleep, restlessness

May develop into confusional state with clinical manifestations

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; El Dareer, 1982; 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, 1993; and WHO Chronicle, 1986.

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. In addition, because of strong cultural prohibitions, women in general may be reluctant to deliver themselves to the care of a male physician; they may actually be prevented from doing so, either by habit or by the realities of seclusion (El Dareer, 1982b).

Psychological Sequelae As is the case everywhere, the psychological impact of a given condition or event is difficult to measure and attribute. Several researchers over the past decade have taken up this elusive aspect of FGM (Armstrong, 1991; Baasher, 1982; Koso-Thomas, 1985; Lightfoot-Klein, 1989). Psychological sequelae of these traditional interventions may begin at the time of the intervention itself or accumulate and emerge in subsequent periods of stress in a woman's life: at menarche, marriage, childbirth, and even in later life. Timing and degree of impact will depend on the type of intervention, the severity and durability of any physical sequelae, and the existence and quality of social support. Marriage may be the most vulnerable period: the long, painful processes of penetration and the potentially grievous repercussions of infertility would appear to lead the list of risks to female health and well-being.

Correlation with HIV Infection Despite speculation, there is no evidence in the published literature of a causal relationship between FGM and HIV infection. Because the procedure is not usually performed under sterile conditions, and because the instrument(s) employed are used in multiple operations during the same ritual event, young women undergoing the surgery could conceivably be at some risk of transmission. A more likely mode of transmission is from an HIV-infected sexual partner, because the possibility of transmission of the infection during intercourse exists when the scarred vagina is subjected to unremitting trauma or lesions through the use of a sharp instrument. This possibility, however, remains at the level of conjecture.

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

TABLE 4-10 Long-Term Complications and Sequelae of Female Circumcision

Complication

Description

Sequelae

Dysuria

Painful or difficult urination

Difficulty increases over time

Chronic urinary retention

Can occur if the urethra is covered, sometimes requiring more surgery

Urinary tract infection(s); formation of calculi, pyelonephritis

Recurrent urinary tract infection

Bridge of skin hiding urinary meatus results in a distorted stream and in the area being constantly wet

Chronic bacterial infection; can ascend to bladder and kidneys, leading to renal failure, septicemia, and death

Chronic infection of the uterus and fallopian tubes

Due to retention of urine and menstrual blood

Severe pain; contributes to primary infertility

Dysmenorrhea

Painful menstruation

If the vagina is too tightly sewn and anal intercourse takes place by choice or by accident, can cause anal fissures and incompetent sphincter

Stenosis

Narrowing of the vagina

Vaginal intercourse difficult; can cause dyspareunia; forcible penetration may cause lacerations of perineum, rectum, and urethra and, possibly, produce formation of a "false vagina"

Hematocolpos and cryptomenorrhea

Complete obstruction of the vagina results in accumulation of menstrual blood in the vagina due to damage to the vaginal walls

Contributes to pelvic infections

Dyspareunia

Painful intercourse

 

Vaginismus

Painful spasm of the vagina

Can prevent or impede intercourse

Implantation dermoid cysts

Very common complication in which a cyst resembling skin grows very large

Cyst can become infected

Keloid formation

Leads to excessive scar tissue

Inability to wash inner epithelial surface of this area, so that skin remains irritated by urine and prone to local bacterial infection; can make later surgery difficult

Calculus formations found in the posterior vaginal fornix (the recess formed between the vaginal wall and the vaginal part of the cervix) or under the bridge of skin that covers the urinary meatus

An abnormal concretion, generally composed of calcium

Can cause obstruction and secondary infection

Retention cyst

Sebaceous substance composed of fat and epithelial debris

Cyst can become infected

Neuroma

Tumor on the nerve to the clitoris

Can cause severe dyspareunia

Disfiguration of external genitalia

 

No physical sequelae

SOURCES: Tables 4-9 through 4-11 are original constructions using many published sources, includingbut not limited to: Aziz, 1980; Bakr, 1982; Cook, 1982; Cutner, 1985;Dorkenoo and Elworthy, 1992; El 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. At the same time, the practices encode central values about gender, male-female relationships, maturity, and community. The resolution of this tension will require a deeper, more comprehensive, and better-quantified understanding than is now the case, in order to develop innovative and constructive solutions to address the negative effects of these practices on Sub-Saharan female health.

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

TABLE 4-11 Obstetric Complications and Sequelae of Circumcision

Complication

Description

Possible Sequelae

Failure to expel fetus during miscarriage or abortion

 

Acute infection, may result in PID and contribute to infertility

Deinfibulation

Cut along the original scar to permit passage of the baby

Infection

Vaginal stenosis

Very small vaginal opening

Vaginal examination during labor very difficult; difficult to assess progress of labor; episiotomy is often necessary for childbirth, including a postero-lateral episiotomy in primigravidae

Episiotomy

Cutting of the skin to prevent tearing

Increased scar tissue; bladder and urethral fistulae injury to anus; late uterine prolapse

Obstructed labor and prolonged second stage of labor, vaginal rupture

Fibrous vulvar tissue fails to dilate during contractions; labor is impeded due to obstruction in the birth canal

Hemorrhage resulting from tearing of scar tissue through cervix or perineum; danger to infant; vesico-vaginal and recto-vaginal fistulae; fistulae can result in incontinence, infection, infertility; bad odor can cause social ostracization

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; El Dareer, 1982; 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 WHOChronicle, 1986.

Health Services
Access to Antenatal and Intrapartum Care

As initially discussed in the section on "Community Characteristics" above, the barriers to maternity care that can affect maternal mortality and morbidity fall into three categories: (1) geographic and convenience factors, (2) acceptability factors, and (3) factors related to quality of care. Although these same barriers exist for both antenatal and intrapartum care, clients are willing to overcome more barriers in the presence of an obstetric complication than they are for routine antenatal care or uncomplicated delivery.

Geographic and Convenience Factors These include distance from the health facility, in miles, time, and cost; weather; terrain; and the availability of transportation. Convenience factors include clinic hours—many clinics are open only in the morning, when women must do their work—and waiting times. 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) centers or primary health care clinics are usually open only a few hours a day, and women experiencing complications may be forced to bypass those facilities and go directly to a hospital, even when the basic facility has the capability to manage the complication.

Acceptability Factors These include the way women are treated when they present for care. Sometimes they are berated for missing appointments, for presenting late in pregnancy, or for not complying with treatment. The social distance between physician and patient is great, even when both are from upper-socioeconomic levels. Patients may not understand instructions, their concerns and traditional practices may be belittled, and they may be given instructions they are unable to follow, such as recommendations to eat nutritious meals and rest more. Women may also be apprehensive about operative deliveries, clinical insistence on an unfamiliar or unacceptable

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

delivery position, isolation from family, and their inability to observe such traditional practices as ritual disposal of the placenta.

Quality of Care Quality of care may be, correctly or incorrectly, perceived as poor. Antenatal care may offer no more than weighing and nutritional information, and the importance of effective measures such as STD screening and measurement of blood pressure and hemoglobin may not be understood. A self-fulfilling prophecy ensures that hospitals are often seen as a place where people die, so women wait far too long to make the journey. People may believe, often justifiably, that the hospital has limited resources and is therefore ineffective. This fuels their reluctance.

Medical facilities in Sub-Saharan Africa do have fewer resources than they need; shortages are acute and tend to worsen when economies decline (Ekwempu et al., 1990). This means that the quality of care in antenatal clinics and obstetric wards is generally low. Much of the antenatal care that is available contributes little to the primary objective of preventing life-threatening complications (Rooney, 1992). The interventions that are effective—blood pressure measurement, management of hypertension, screening and treatment of sexually transmitted and parasitic diseases, supplemental iron and folic acid, and patient education in the significance and management of symptoms of impending complications—are sometimes unavailable. Some hospitals are often unprepared to manage the most extreme complications, and sometimes lack the human and material resources to manage the common obstetric emergencies. This leads to documented higher case-fatality rates and the failure to command community confidence.

This lack of response capacity is exacerbated by medical inflexibility. Formally trained providers are not always prepared to adapt maternity care to the special needs of poor and illiterate women, and the traditional organization of medical training around treatments of first choice means that providers are not prepared to make do with second and third treatment options. Maternal death case reviews suggest that when first-line pharmaceuticals are not available, many physicians are unaware of alternatives or unprepared to innovate when the resource base is less than ideal. While it seems far-fetched to count lack of imagination as yet another cause of maternal death, this may sometimes be the case.

Still, some highly innovative and workable alternatives have been developed in the region. In Zaire, nursing persons have been trained to do cesarean deliveries, laparotomies, and hysterectomies, and their case-fatality rates have been about the same as those for physicians (White et al., 1987). In Mozambique, "surgical technicians" are trained to perform surgical procedures, including obstetric procedures. In both situations, physicians are on call if needed. As one more example, there is the role-expanding approach used by the Ghana Registered Midwives Association that focuses on "Life-Saving Skills" for midwives. The idea of assigning greater responsibilities to midwives, however, has generally been resisted by the larger medical community (Carnegie Corporation, 1993).

MATERNAL HEALTH AND FAMILY PLANNING

Broadly speaking, maternal mortality and morbidity can be reduced by decreasing the absolute number of times all women become pregnant, the number of pregnancies among high-risk women, the number of unwanted pregnancies that might otherwise end in abortion, and by making pregnancy and childbirth safer.

Women not contracepting are likely to have more pregnancies, each of which adds to overall risk, a risk further increased by the growing likelihood that women whose pregnancies are unwanted will resort to clandestine abortion. Women with unwanted pregnancies are also more likely to be at the extremes of the reproductive period (too old or too young), of high parity, and are less likely to seek prenatal care, all of which further jeopardizes their health and elevates their risk status (Royston and Armstrong, 1989; WHO, 1987b). They may also be less economically, socially, or psychologically prepared for pregnancy, further compounding their existing health problems.

The Demographic and Health Surveys (DHS) show that African women continue having children even when they do not wish to do so (see Table 4-12). 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. In Mauritius, 70 percent of the women responded that they did not want any more children, and

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

TABLE 4-12 Fertility Desires Among Currently Married Women Aged 15–44, DHS and Family Planning Surveys, 1985–1991 (percent)

Country and Year

Pregnant

Want More Children Nowa

Want More Children Laterb

Want No More Children

Are Using Family Planningc

Botswana, 1988

10

25

33

32

35

Burundi, 1987

15

15

52

18

9

Ghana, 1988

14

20

47

19

13

Kenya, 1988–1989

13

13

28

46

27

Liberia, 1986

17

33

36

14

6

Mali, 1987

16

34

36

13

5

Mauritius, 1985d

8

22

22

70

75

Nigeria, 1990

16

34

37

13

5

Senegal, 1986

22

14

44

21

12

Sudan, 1989–1990

16

32

32

21

9

Togo, 1988

14

19

48

20

12

Uganda, 1988–1989

27

36

32

15

5

Zimbabwe, 1988–1989

14

22

37

28

45

a Want more children within 2 years.

b Want more children after 2 years or longer.

c Currently using any method of family planning.

d The Mauritius Survey asked pregnant women whether they wanted another child, but not when they wanted one.

SOURCE: Robey et al., 1992.

75 percent were using family planning. Women in Burundi were obviously at greater risk of an unwanted pregnancy than their Mauritian counterparts.

If African women were to have only the number of children they say they want, there would be 4 million fewer births, a 17 percent decrease (Maine et al., 1987). Maternal deaths would fall in comparable proportion, simply by diminishing the numerical risk of dying as a result of pregnancy (Royston and Armstrong, 1989).

In Africa, family planning could lower maternal mortality risk by changing the profile of parity history (Maine et al., 1987; Winikoff and Sullivan, 1987). In a reanalysis of Harrison and Rossiter's (1985) hospital-based data from Zaria, Northern Nigeria, Winikoff and Sullivan (1987) show that preventing births above para four would have resulted in a 52 percent reduction in mortality among the patients; preventing births below age 20, over age 30, and above para 4 would have reduced maternal mortality by 66 percent. These data suggest that appreciable gains in maternal survival could be realized by concentrating childbearing during the safest years of female reproductive life.

A review of abortion data leads to similar conclusions. Results from a community-based study in Addis Ababa by Kwast and colleagues (1986) suggest that if all pregnancies that ended in abortion had been prevented by contraception, direct obstetrical deaths would have been reduced by 54 percent. In Cameroon, where abortion-related mortality at a local hospital was 56 times higher than mortality from all other causes in the same unit (Leke, 1989), and in Benin City, Nigeria, where a hospital-based study reported that abortions accounted for one-fifth of all maternal deaths (Unuigbe et al., 1988a,b), prevention of those pregnancies alone would have significantly reduced maternal mortality. In addition to mortality reduction, there would have been substantial reduction in morbidity and liberation of hospital beds and resources for other pressing needs.

Although statistically it seems to make more sense to target family planning programs at all high-risk groups, Winikoff and Sullivan (1987) 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), acceptance of family planning among this group would be low because its members are under great pressure to commence childbearing immediately.

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

TABLE 4-13 Reproductive Risk: Mortality Rates Associated with Childbearing, Compared with Mortality Rates Associated with Contraceptive Use

 

Estimated Annual Deaths per 100,000 Women

 

Developed Countries

Developing Countries

 

Age<35

Age 35+

Age<35

Age 35+

Maternal deaths with no contraception

10

27

60

160

Deaths from side-effects of oral contraceptives among nonsmokers

1

23

1

23

Deaths from side-effects of IUDs

1

2

2

4

Deaths from side-effects of condoms

0

0

0

0

SOURCE: Adapted from Rinehart, 1987.

Although contraceptive use remains low in most of Sub-Saharan Africa, it has risen appreciably. In Zimbabwe, Botswana, and Kenya, use of modern methods has risen sharply since the 1980s, and fertility has shown a corresponding decline (Robey et al., 1992). The dangers of contraceptives are often cited as reasons for nonuse, yet when the safety of contraceptives is compared with the risks associated with pregnancy, especially as those risks accumulate, contraceptive use proves to be far safer than childbearing (see Table 4-13).

Provision of Family Planning Services

Family planning service provision is a complicated process, entangled in social, political, moral, and cultural debate in many African countries. Services to teenagers, who would benefit with significant mortality reduction, are often tightly restricted. 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. Even if the social and political debates were resolved, there remain many reasons for nonuse: side-effects are a significant concern; method failure is not uncommon; and refusal on religious grounds remains salient. To be successful, family planning programs must be sensitive to these reservations and to the community being served, and services must be delivered in a manner that meets users' needs.

Access to family planning services is restricted for many of the same reasons that affect access to health care services overall: insufficient governmental commitment, lack of knowledge about services, distance, and logistics. There are also social barriers, such as requirements for spousal permission or proof of a given number of living children, and encounters with the medical establishment can be intimidating for women. If family planning is not integrated into other services that have some logical affinity (MCH, STD screening, infertility management, and activities for enhancing women's skills), it is marginated, theoretically and practically, in ways that constrain both access and effectiveness (Herz and Measham, 1987; Raikes, 1989; Royston and Armstrong, 1989). This limitation also affects women's ability to gain sufficient knowledge about family planning, as well as an adequate understanding of their options, to make informed decisions. According to the DHS, fewer than 40 percent of women in Burundi, Ghana, Liberia, Mali, Niger, Senegal, and Uganda are able to name any modern family planning method (Robey et al., 1992).

Cost is another impediment. Although contraceptives are provided free by many government-based sources, private outlets continue to be crucial for women who place a premium on confidentiality. In Nigeria, over half the family planning outlets are private pharmacists and chemists, and less than 40 percent of current users of modern methods obtain their contraceptives from hospitals (Johns Hopkins University, 1992). Recent efforts in some Sub-Saharan

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

countries to require clients to pay part of the cost of family planning methods will inevitably have some effect on utilization.

It is not unreasonable to argue that because of the clear relationship between childbearing and female health, women will be able to improve their health status significantly when they have made significant gains in reproductive freedom, and family planning programs are conceptually and practically integrated into health programs and overall thinking about the meaning of development.

Abortion

Part of societal reaction to voluntary termination of pregnancy in Sub-Saharan Africa is rooted in strong traditional and religious sentiments. A large portion of the population adheres to pronatalist beliefs deriving from a Christian-Islamic cultural heritage. This, in turn, affects the way abortion and contraceptive services are delivered. In Kenya, maternal and child health services were initially provided by missionaries, contraception was not promoted, and abortion was illegal. Little of this was changed in most African countries after independence (Raikes, 1989). Even in Zambia, where abortion is legal, 25 incomplete abortions are treated for every abortion that is performed legally (Bradley et al., 1991).

Assertions that abortion is relatively rare in Sub-Saharan Africa are not supported by the evidence (Coeytaux, 1988). Because it is so restricted and services are poor even where laws are liberal, most abortions are clandestine or occur out of hospital, and prevalence data therefore present far from the real picture. A growing body of evidence indicates that abortions may account for at least half the maternal mortality in the entire region (Kwast et al., 1986; Rosenfield, 1989).

The large majority of clandestine abortions end up in a hospital as incomplete—and usually septic—abortions. Major hospitals in Nairobi and Kinshasa, which reported 2,000 to 3,000 admissions a year for abortion complications in the late 1970s and early 1980s (Aggarwal and Mati, 1982), were treating 30 to 60 a day by the end of the decade (Rogo et al., 1987), or about 10,000 a year, a fivefold increase (Coeytaux, 1988).

Because it is clandestine, abortion is characteristically performed under unsanitary conditions, and is thus a significant contributor to infection, infertility, and mortality among women of all ages. In Kenya, Aggarwal and Mati (1982) report that only 11 percent of the abortions they reviewed had been performed by qualified personnel. In Cameroon, the abortion-related mortality rate at a local hospital was 56 times higher than mortality from other causes in the same maternity unit (Leke, 1989). In Addis Ababa, Kwast and colleagues (1986) found that the main cause of maternal mortality was septic abortion, which accounted for 54 percent of the direct obstetric deaths. In Benin City, Nigeria, abortions—only 10 percent of which were spontaneous—accounted for one-fifth of all maternal deaths (Unuigbe et al., 1988a,b), and Odejide (1986) reports illegal abortion as the leading cause of death among unmarried women aged 15–24, particularly those in school. At the University of Calabar Teaching Hospital, Archibong (1991) estimated that 20 percent of the maternal deaths 40 percent of all gynecological admissions were abortion-related. In Cameroon, Leke (1989) reported that abortion was responsible for one-third of the emergency hospital admissions to a principal maternity hospital. In a review of 123 maternal deaths in Guinea (Conakry), Toure and colleagues (1992) found that abortion was the third leading cause of mortality, after hypertension and postpartum bleeding. 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. Most of this research, however, in hospital-based, revealing nothing about those unable to obtain medical services, and it provides only a hint of the magnitude of the problem (Coeytaux, 1988).

Abortion is a major health problem for women of all ages, marital status, and socioeconomic strata in Sub-Saharan Africa. Crowther (1986) reports that, of 99 patients who had an abortion at Haarare Hospital in Zimbabwe, 76 percent were married, more than half were over 30, and nearly 35 percent had more than four children. In Addis Ababa, Kwast and colleagues (1986) found that of 13 women who died of direct obstetric complications of abortion, over half were married and nearly 70 percent were over 20. In Nigeria, Odejide (1986) found abortion to be the course of action among 90 percent of unmarried and working women with unwanted pregnancies. In their study of 1,800 never-married Nigerian adolescents and young women aged 14–25, Nichols and colleagues (1986)

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

reported that almost half the female students and two-thirds of the female nonstudents had been pregnant, and nearly all had terminated their pregnancies with an induced abortion.

In general, abortion predominates among younger, single, educated women in the higher social classes. Education, employment, and urbanization have contributed to delays in family formation, and many women with these characteristics who find themselves pregnant will resort to abortion (Boerma, 1987). Abortions, however, are not restricted to urban areas, as popular wisdom would have it. A Kenya study shows that rural women are just as likely to have an abortion as urban women (Lema et al., 1989; Mbizvo et al., 1993).

The infections that so often accompany illicit abortions have their own sequelae. In addition to immediate complications, such infections may spread throughout the reproductive tract and produce PID, with tubal damage, secondary infertility, and predisposition to ectopic pregnancy (Meheus, 1992). The procedure itself may cause mechanical damage to the vagina, cervix, or uterus, and chemicals introduced into the vagina may destroy tissue, which can also contribute to infection; cervical lacerations may be responsible for subsequent miscarriage or premature births (Aggarwal and Mati, 1982). In Nigeria, Oronsaye and Odiase (1981) found that 22 percent of women who presented with ectopic pregnancies had histories of abortion, nearly three times the number of those who had experienced "normal" pregnancies.

Illegal abortion also makes great demands upon health systems. Complicated abortion uses scarce hospital resources that would otherwise be available to other patients. At Kenyatta National Hospital during one six-month period, 60 percent of the beds in the Acute Gynecological Ward were occupied by abortion patients (Aggarwal and Mati, 1982). In 1968 –1969, 41 percent of the blood supply of the major referral hospital in Ghana was used to treat the sequelae of such abortions (Gyepi-Gabrah, 1985). Current issues with the blood supply are somewhat different: women in Zambia who need transfusions for abortion-related hemorrhage refused them for fear of AIDS (Castle et al., 1990).

The question of who makes decisions about abortion is as critical in Sub-Saharan Africa as it is in many other parts of the world. In Zambia, where the laws, exemplified by the Termination of Pregnancy Act, are more liberal than elsewhere in Africa, a woman still must obtain written consent from three physicians who attest to the negative physical or mental consequences to her or her children of a continued pregnancy (Castle et al., 1990). A similar law, the Abortion and Sterilization Act, is in force in South Africa, but only one-third of those who filed for abortion for mental reasons under this act were granted permission; some of the remainder turned to illegal means and, in 1987 alone, nearly 15,000 operations were performed in South Africa to remove the residues of incomplete abortion (Nash, 1990). As elsewhere in the world, ambivalence remains; a study in Nigeria found that 35 percent of women seeking abortions were opposed to legalization (Ujah, 1991).

Lactation

The benefits of breastfeeding are well established and breast milk is recognized as the best form of nutrition for infants. It contains all the nutrients needed in the first few months of life, meets those needs at no economic cost, confers some immunity against infection on the infant through its mother's antibodies, and is preferable to bottle-feeding because the risk of contamination is reduced. Breastfeeding may also protect the mother against anemia and more general depletion by reducing postpartum hemorrhage, delaying return of menses, and contributing to the length of birth intervals. It also facilitates return of the uterus to its normal size and provides emotional bonding between mother and infant (McCann et al., 1984).

Although duration of breastfeeding is declining, particularly in urban areas, it is still almost universal in Africa. Table 4-14 shows that median duration of any breastfeeding in Sub-Saharan Africa ranges from 18 months in Botswana to 26 months in Burundi. Exclusive breastfeeding is brief, however, and most mothers begin supplementing breast milk between the baby's first and seventh month. 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. Production of breast milk requires

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

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

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

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

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

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

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

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

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

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

Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
×

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.

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Suggested Citation:"4 Obstetric Morbidity and Mortality." Institute of Medicine. 1996. In Her Lifetime: Female Morbidity and Mortality in Sub-Saharan Africa. Washington, DC: The National Academies Press. doi: 10.17226/5112.
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The relative lack of information on determinants of disease, disability, and death at major stages of a woman's lifespan and the excess morbidity and premature mortality that this engenders has important adverse social and economic ramifications, not only for Sub-Saharan Africa, but also for other regions of the world as well. Women bear much of the weight of world production in both traditional and modern industries. In Sub-Saharan Africa, for example, women contribute approximately 60 to 80 percent of agricultural labor. Worldwide, it is estimated that women are the sole supporters in 18 to 30 percent of all families, and that their financial contribution in the remainder of families is substantial and often crucial.

This book provides a solid documentary base that can be used to develop an agenda to guide research and health policy formulation on female health—both for Sub-Saharan Africa and for other regions of the developing world. This book could also help facilitate ongoing, collaboration between African researchers on women's health and their U.S. colleagues. Chapters cover such topics as demographics, nutritional status, obstetric morbidity and mortality, mental health problems, and sexually transmitted diseases, including HIV.

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