Reproductive Health in Developing Countries Expanding Dimensions, Building Solutions (1997) / Chapter Skim
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Pages 116-145
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116 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES 116 5 Healthy Pregnancy and Childbearing An estimated 585,000 women die each year from pregnancy-relatedcauses (World Health Organization and UNICEF, 1996)
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HEALTHY PREGNANCY AND CHILDBEARING 117 T A B L E 5 -1 M at er na l M or ta lit y by M aj or R eg io ns , C ir ca 1 99 0 M at er n al D ea th s M at er n al M or ta li ty R at io T ot al F er ti li ty R at e (d ea th s p er 1 00 ,0 00 L if et im e R eg io n (b ir th s p er w om an )
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From page 118... ...
118 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES rect causes, those that are aggravated by pregnancy but may be present even before pregnancy, such as diabetes, malaria, or hepatitis. Approximately 80 percent of all maternal deaths are estimated to be due to direct causes (World Health Organization, 1996)
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HEALTHY PREGNANCY AND CHILDBEARING 119 serious complications were infrequent (postpartum bleeding, 7 percent, convulsions, 2 percent, and postpartum sepsis, 5 percent (De GraftJohnson, 1994)
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120 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES Anemia Given its high prevalence and impact on the lives and survival chances of women and newborns, anemia (hemoglobin counts below 11 g/dl) deserves special mention.
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HEALTHY PREGNANCY AND CHILDBEARING 121 Other common micronutrient deficiencies -- particularly iodine and vitamin A -- are also known to have similar negative pregnancy outcomes. Obstetric Fistula and Genital Prolapse Two chronic conditions warrant attention because of their high prevalence and devastating consequences -- obstetric fistula and genital prolapse.
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122 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES ated with high parity and is often the result of damage during childbirth to the muscles and ligaments that support those organs. Genital prolapse is extremely uncomfortable, particularly for women who undertake chores in a squatting position, as is common in low-income and rural settings in developing countries .
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HEALTHY PREGNANCY AND CHILDBEARING 123 born could reduce this enormous death toll (World Health Organization, 1994a)
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124 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES and informal surveys, although it is argued that this association is due to selection bias -- that is, the women who use prenatal services are also more likely to take better care of themselves and use delivery services (Rooney, 1992)
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From page 125... ...
HEALTHY PREGNANCY AND CHILDBEARING 125 Egypt, only 16.4 percent of deaths occurred among women aged less than 20 or more than 40 years, two common demographic factors. Although these women have a higher risk of death, the numbers of such women are low in comparison with women who die between 20-40 years of age simply because most pregnancies occur to women aged 20-40 (Ministry of Health, 1994)
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126 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES et al.
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HEALTHY PREGNANCY AND CHILDBEARING 127 stood, and the relative importance of the degree and timing during pregnancy of the symptoms (hypertension, proteinuria, edema, or other biochemical abnormalities) is unclear (Rooney, 1992)
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From page 128... ...
128 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES In the Philippines, tetanus toxoid injections have been given to all adolescent girls to increase the probability that they will be adequately protected the first time they give birth. Reproductive tract infections, including sexually transmitted diseases, should also be screened for and treated during prenatal care.
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From page 129... ...
HEALTHY PREGNANCY AND CHILDBEARING 129 Essential Care for Obstetric Complications Since the major causes of maternal mortality cannot be predicted or prevented well enough during pregnancy to allow reliance on primary prevention and screening, improvements in maternal death rates will require that women have access to facilities with trained providers and equipment that can carry out essential care of obstetric complications. Defined by WHO first in 1985 with refinements made in 1995 (World Health Organization, 1995)
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130 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES between 1750 and 1980, with two-thirds of the decrease occurring in the eighteenth and nineteenth centuries. This decline, not reported in other European countries, has been attributed to home-assisted births by trained midwives and the use of aseptic techniques.
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HEALTHY PREGNANCY AND CHILDBEARING 131 medical services for delivery, while in the other one-half of the countries less than 50 percent did so. Latin American and Caribbean countries have somewhat higher coverage rates than sub-Saharan African countries.
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132 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES Pathway to Maternal Survival Since most women in developing countries experience labor and delivery outside the formal health care system, we discuss obstetric care under a four-step pathway to maternal survival, assuming that labor begins for a woman in her home (see also Thaddeus and Maine, 1994)
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HEALTHY PREGNANCY AND CHILDBEARING 133 this view comes from focus groups with pregnant and recently delivered women in projects in rural areas of West Java, Indonesia, Bangladesh, and Nigeria; in rural and urban settings in Jamaica; and a periurban/urban area of Bolivia (see Appendix B)
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134 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES Bleeding stands out as the one maternal complication that commands attention almost everywhere. During pregnancy, or in the intrapartum or postpartum periods, the extent of bleeding is watched apprehensively -- "bad" blood must leave the body, but "good" blood must remain.
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HEALTHY PREGNANCY AND CHILDBEARING 135 others said 1 to 3 days. If labor lasts longer than normal, the woman is given hot teas and massage.
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136 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES At home it's private, you don't pay anything.
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HEALTHY PREGNANCY AND CHILDBEARING 137 Thaddeus and Maine, 1994)
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138 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES In five districts in Bolivia, no obstetricians or anesthesiologists were found in two of the district hospitals. In a large urban district, no blood bank was available to support the district hospitals.
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HEALTHY PREGNANCY AND CHILDBEARING 139 ciencies in the systems of care available and to a large gap between what facilities and life-saving skills are available and what is needed. Indicators of the quality of emergency care for obstetric complications at a facility include the time interval between admission to treatment, facility trends in case-fatality rates for all complications, the caesarean section rate, and trends in numbers of deaths (maternal and perinatal)
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140 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES agement and diagnosis by obstetric teams -- 47 percent. Patient factors, particularly delay in seeking (or compliance with)
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HEALTHY PREGNANCY AND CHILDBEARING 141 Step 1: Recognition of a Problem What seems like a simple and obvious lesson comes from projects in West Java, Indonesia (Alisjahbana et al., 1995) , Bolivia (Howard-Grabman, Seoane, and Davenport, 1993; Bower and Perez, 1993)
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142 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES women no longer seek assistance because it is known that many women will be referred to an expensive setting. This problem must be addressed through a communications effort directed to women and their families.
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HEALTHY PREGNANCY AND CHILDBEARING 143 positively disposed to using them. Distance to a referral site may be an obstacle, but three experiments aimed at ensuring transport, with taxi subsidies (Poedje et al., 1993)
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144 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES home to be effective, a high proportion of women must attend an prenatal clinic, there must be an effective screening and referral system in place, and hospital delivery must be acceptable to mothers." Yet another alternative, birthing homes, where medically trained personnel can be called to assist in a difficult delivery at some distance from a hospital, have been tried in Forteleza, Brazil, as well as in Tanjungsari in West Java. The birthing homes with traditional birth attendants did not appear as attractive to women as either home or hospital delivery.
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HEALTHY PREGNANCY AND CHILDBEARING 145 with a remarkable drop in avoidable factors assigned to the staff, emphasizing the pediatric staff's improved response to newborn problems (Schieber et al., 1995)
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