chapter four attending to 136 million births, every year For both mother and baby childbirth can be the most dangerous moment in life. This chapter examines the main complications of childbirth, which claim an estimated 529 000 maternal deaths per year-almost all of them in developing countries. Most of the deaths and disabilities attributable to childbirth are avoidable, because the medical solutions are well known immediate and effective professional care during and after labour and delivery can make the difference between life and death for both women and their newborns. each and every mother and each and every newborn needs skilled maternal and neonatal care provided by professionals at and after birth-care that is close to where and how people live, close to their birthing culture, but at the same time safe, with a skilled professional able to act immediately when largely unpredictable complications occur. The challenge that remains is therefore not technological but strategic and organizationa RISKING DEATH TO GIVE LIFE well known. The challenge that remains is therefore not For anyone who has been through the experience, or seen technological, but strategic and organizational else go through it, there is no doubt that childbirth is a life-ch Maternal mortality is currently estimated at 529 000 event. Unfortunately, as wonderful and joyful experience as deaths per year( 2), a global ratio of 400 maternal many, it can also be a difficult period, bringing with it new problems deaths per 100 000 live births. Where nothing is done as well as the potential for suffering In the most extreme cases the to avert maternal death, "natural"mortality is around mother, or the baby, or both, may die; these deaths are only the tip of 1000-1500 per 100 000 births, an estimate based on the iceberg Many health problems are laid down in the critical hours historical studies and data from contemporary reli of childbirth- both for mother and for child. Many more continue to gious groups who do not intervene in childbirth (3) unfold in the days and weeks after the birth the suffering related to women were still experiencing "natural"maternal mor- childbirth adds up to a significant portion of the world s overall tally tality rates today -if health services were discontin of ill-health and death(1). Most of the deaths and disabilities attrib- ued, for example- then the maternal death toll would utable to childbirth are avoidable because the medical solutions are be four times its current size, totalling over two million
61 chapter four attending to 136 million births, every year RISKING DEATH TO GIVE LIFE For anyone who has been through the experience, or seen someone else go through it, there is no doubt that childbirth is a life-changing event. Unfortunately, as wonderful and joyful experience as it is for many, it can also be a difficult period, bringing with it new problems as well as the potential for suffering. In the most extreme cases the mother, or the baby, or both, may die; these deaths are only the tip of the iceberg. Many health problems are laid down in the critical hours of childbirth – both for mother and for child. Many more continue to unfold in the days and weeks after the birth. The suffering related to childbirth adds up to a significant portion of the world’s overall tally of ill-health and death (1). Most of the deaths and disabilities attributable to childbirth are avoidable, because the medical solutions are well known. The challenge that remains is therefore not technological, but strategic and organizational. Maternal mortality is currently estimated at 529 000 deaths per year (2), a global ratio of 400 maternal deaths per 100 000 live births. Where nothing is done to avert maternal death, “natural” mortality is around 1000–1500 per 100 000 births, an estimate based on historical studies and data from contemporary religious groups who do not intervene in childbirth (3). If women were still experiencing “natural” maternal mortality rates today – if health services were discontinued, for example – then the maternal death toll would be four times its current size, totalling over two million For both mother and baby, childbirth can be the most dangerous moment in life. This chapter examines the main complications of childbirth, which claim an estimated 529 000 maternal deaths per year – almost all of them in developing countries. Most of the deaths and disabilities attributable to childbirth are avoidable, because the medical solutions are well known. Immediate and effective professional care during and after labour and delivery can make the difference between life and death for both women and their newborns. Each and every mother and each and every newborn needs skilled maternal and neonatal care provided by professionals at and after birth – care that is close to where and how people live, close to their birthing culture, but at the same time safe, with a skilled professional able to act immediately when largely unpredictable complications occur. The challenge that remains is therefore not technological, but strategic and organizational
62 The World Health Report 2005 maternal deaths per year worldwide. The truth is that three quarters of these deaths are currently avoided throughout the world: nearly all the"natural "maternal mortality in developed countries, but only two thirds in the South-East Asia and Eastern Medi- terranean Regions and only one third in African countries There are immense variations in death rates in different parts of the world. Maternal deaths are even more inequitably spread than newborn or child deaths. a tiny 1% of maternal deaths occur in the developed world. Maternal mortality ratios range from 830 per 100 000 births in African countries to 24 per 100 000 births in European countries. Of the 20 countries with the highest maternal mortality ratios, 19 are in sub-Saharan Africa. Regional rates mask very large disparities between countries. Re gions with low overall mortality rates, such as the European Region, contain countries with high rates. Within one single country there can be striking differences between subgroups of the population. Rural populations suffer higher mortality than urban dwellers, rates can vary widely by ethnicity or by wealth status, and remote areas bear a heavy Maternal deaths are deaths from pregnancy-related complications occurring through out pregnancy, labour, childbirth and in the postpartum period (up to the 42nd day after the birth). Such deaths often occur suddenly and unpredictably. Between 11% and 17% of maternal deaths happen during childbirth itself and between 50% and 71% in the postpartum period(4-8). The fact that a high level of risk is concentrated during childbirth itself, and that many postpartum deaths are also a result of what hap- pened during birth, focuses attention on the hours and sometimes days that are spent in labour and giving birth, the critical hours when a joyful event can suddenly turn into an unforeseen crisis. The postpartum period- despite its heavy toll of deaths-is often neglected (4, 9). Within this pe Figure 4.1 Causes of maternal death riod, the first week is the most prone to risk. About 45%of postpartum maternal deaths occur during the first 24 hours Severe bleeding and more than two thirds during the first Indirect causes week(4 The global toll of postpartum maternal deaths is accompanied by the great and often overlooked number of early newborn deaths and stillbirths. Maternal deaths result from a wide range of indirect and direct causes. Other direct causes represent 20% of the global total. They are caused by diseases (pre-existing or concurrent) that are not complications of pregnancy, but complicate pregnancy Infections or are aggravated by it. These include malaria, anaemia. HiviaiDs and cardio vascular disease. Their role in maternal mortality varies from country to country, according to the epidemiological context obstructed and the health systems effectiveness in The lion s share of maternal deaths Total is more than 100% due to rounding is attributable to direct causes. Direct
62 The World Health Report 2005 maternal deaths per year worldwide. The truth is that three quarters of these deaths are currently avoided throughout the world: nearly all the “natural” maternal mortality in developed countries, but only two thirds in the South-East Asia and Eastern Mediterranean Regions and only one third in African countries. There are immense variations in death rates in different parts of the world. Maternal deaths are even more inequitably spread than newborn or child deaths. A tiny 1% of maternal deaths occur in the developed world. Maternal mortality ratios range from 830 per 100 000 births in African countries to 24 per 100 000 births in European countries. Of the 20 countries with the highest maternal mortality ratios, 19 are in sub-Saharan Africa. Regional rates mask very large disparities between countries. Regions with low overall mortality rates, such as the European Region, contain countries with high rates. Within one single country there can be striking differences between subgroups of the population. Rural populations suffer higher mortality than urban dwellers, rates can vary widely by ethnicity or by wealth status, and remote areas bear a heavy burden of deaths. Maternal deaths are deaths from pregnancy-related complications occurring throughout pregnancy, labour, childbirth and in the postpartum period (up to the 42nd day after the birth). Such deaths often occur suddenly and unpredictably. Between 11% and 17% of maternal deaths happen during childbirth itself and between 50% and 71% in the postpartum period (4–8 ). The fact that a high level of risk is concentrated during childbirth itself, and that many postpartum deaths are also a result of what happened during birth, focuses attention on the hours and sometimes days that are spent in labour and giving birth, the critical hours when a joyful event can suddenly turn into an unforeseen crisis. The postpartum period – despite its heavy toll of deaths – is often neglected (4, 9). Within this period, the first week is the most prone to risk. About 45% of postpartum maternal deaths occur during the first 24 hours, and more than two thirds during the first week (4). The global toll of postpartum maternal deaths is accompanied by the great and often overlooked number of early newborn deaths and stillbirths. Maternal deaths result from a wide range of indirect and direct causes. Maternal deaths due to indirect causes represent 20% of the global total. They are caused by diseases (pre-existing or concurrent) that are not complications of pregnancy, but complicate pregnancy or are aggravated by it. These include malaria, anaemia, HIV/AIDS and cardiovascular disease. Their role in maternal mortality varies from country to country, according to the epidemiological context and the health system’s effectiveness in responding (10). The lion’s share of maternal deaths is attributable to direct causes. Direct Severe bleeding (haemorrhage) 25% Infections 15% Eclampsia 12% Obstructed labour 8% Unsafe abortion 13% Indirect causes 20% Other direct causes 8% a Total is more than 100% due to rounding. Figure 4.1 Causes of maternal deatha
attending to 136 million births, every year 63 maternal deaths follow complications of pregnancy and childbirth, or are caused by any interventions, omissions, incorrect treatment or events that result from these complications, including complications from(unsafe)abortion. The four other major direct causes are haemorrhage, infection, eclampsia and obstructed labour (see Fig ure 4.1). The levels of matemal mortality depend on whether these complications are dealt with adequately and in a timely manner(10) he most common cause of maternal death is severe bleeding, a major cause of death in both developing and developed countries (11, 12 ). Postpartum bleeding can kill even a healthy woman within two hours, if unattended. It is the quickest of mater nal killers. An injection of oxytocin given immediately after childbirth is very effective in reducing the risk of bleeding. In some cases a fairly simple-but urgent- interven- tion such as manual removal of the placenta may solve the problem. Other women may need a surgical intervention or a blood transfusion, both of which require hospitaliza tion with appropriate staff, equipment and supplies. The proportion needing hospital care depends, to some extent, on the quality of the first-level care provided to women for example, active management of the third stage of labour reduces postpartum bleeding. The proportion that dies depends on whether appropriate care is provided apidly. The situation with regard to postpartum bleeding could improve if the promis- ing potentialities of the drug misoprostil are realized. Misoprostil is less effective than oxytocin, but it is cheaper, easier to store safely and does not require an injection. Therefore it remains attractive where women do not have access to professional care at birth. If further research can demonstrate its effectiveness in the many cases where oxytocin is not an option, misoprostil could save many lives and reduce the number of women who suffer anaemia as a result of a postpartum haemorrhage - currently 1.6 million every year. The second most frequent direct cause of death is sepsis, responsible for most late postpartum deaths. During the 19th century puerperal sepsis took on epidemic propor- tions, particularly in lying-in hospitals. The introduction of aseptic techniques brought a spectacular reduction of its importance in the developed word (13). However, sepsis is still a significant threat in many developing countries. One out of 20 women giving Table 4.1 Incidence of major complications of childbirth, worldwide Number Case-fatality Main sequelae DALYs lost (%0f of cases r survivors (000) live births) per year Postpartum 10.5 13 795 000 1 132 000 Severe anaemia 4 418 haemorrhage Sepsis 4.4 5768000 1.3 79000 Infertility Pre-eclampsia 4152000 63000 Not well evaluated 2 231 and eclampsia Obstructed labour 4.6 6038000 0.7 42000 incontinence
attending to 136 million births, every year 63 maternal deaths follow complications of pregnancy and childbirth, or are caused by any interventions, omissions, incorrect treatment or events that result from these complications, including complications from (unsafe) abortion. The four other major direct causes are haemorrhage, infection, eclampsia and obstructed labour (see Figure 4.1). The levels of maternal mortality depend on whether these complications are dealt with adequately and in a timely manner (10). The most common cause of maternal death is severe bleeding, a major cause of death in both developing and developed countries (11, 12). Postpartum bleeding can kill even a healthy woman within two hours, if unattended. It is the quickest of maternal killers. An injection of oxytocin given immediately after childbirth is very effective in reducing the risk of bleeding. In some cases a fairly simple – but urgent – intervention such as manual removal of the placenta may solve the problem. Other women may need a surgical intervention or a blood transfusion, both of which require hospitalization with appropriate staff, equipment and supplies. The proportion needing hospital care depends, to some extent, on the quality of the first-level care provided to women; for example, active management of the third stage of labour reduces postpartum bleeding. The proportion that dies depends on whether appropriate care is provided rapidly. The situation with regard to postpartum bleeding could improve if the promising potentialities of the drug misoprostil are realized. Misoprostil is less effective than oxytocin, but it is cheaper, easier to store safely and does not require an injection. Therefore it remains attractive where women do not have access to professional care at birth. If further research can demonstrate its effectiveness in the many cases where oxytocin is not an option, misoprostil could save many lives and reduce the number of women who suffer anaemia as a result of a postpartum haemorrhage – currently 1.6 million every year. The second most frequent direct cause of death is sepsis, responsible for most late postpartum deaths. During the 19th century puerperal sepsis took on epidemic proportions, particularly in lying-in hospitals. The introduction of aseptic techniques brought a spectacular reduction of its importance in the developed world (13). However, sepsis is still a significant threat in many developing countries. One out of 20 women giving Table 4.1 Incidence of major complications of childbirth, worldwide Complication Incidence Number Case-fatality Maternal Main sequelae DALYs lost (% of of cases rate (%) deaths in for survivors (000) live births) per year 2000 Postpartum 10.5 13 795 000 1 132 000 Severe anaemia 4 418 haemorrhage Sepsis 4.4 5 768 000 1.3 79 000 Infertility 6 901 Pre-eclampsia 3.2 4 152 000 1.7 63 000 Not well evaluated 2 231 and eclampsia Obstructed labour 4.6 6 038 000 0.7 42 000 Fistula, 2 951 incontinence Source: (12)
64 The World Health Report 2005 birth develops an infection, which needs prompt treatment so as not to become fatal or leave sequelae (14 ). Puerperal sepsis leads to tubal occlusion and infertility in 450 000 women per year. Hypertensive disorders of pregnancy(pre-eclampsia and eclampsia)-which are as- sociated with high blood pressure and convulsions- are the cause of 12% of maternal deaths. They usually occur during pregnancy but also during childbirth(15). Mild pre eclampsia can be monitored in pregnancy, but the transition to severe pre-eclampsia or eclampsia requires care in a hospital environment. Obstructed labour -owing to disproportion between the fetal head and the mother's pelvis, or to malposition or malpresentation of the fetus during labour varies in incidence:as low as 1% in some populations but up to 20%in others.It accounts for around 8%of maternal deaths globally, while the baby may be stillborn, suffer asphyxia and brain damage or die soon after birth. Skilled practitioners, such as mid- wives, can deal with many of these problems before labour becomes obstructed, or recognize slow progress and refer for caesarean section or instrumental delivery. Dis abilities associated with obstructed labour that is dealt with late or inadequately can be very significant both for mother and child(12). For the mother the most distressing potential long-term conditions following obstructed labour are obstetric fistulae(see B0x4.1) Of the 136 million women who give birth each year, some 20 million experience preg- nancy-related illness after birth(30 ) The list of morbidities is very diverse, ranging from fever to psychosis, and the range of care responses needed is correspondingly varied. For those women who have almost died in childbirth, recovery from organ failure, uterine rupture, fistulas and other severe complications can be long, painful and leave lasting sequelae. Other, non-life-threatening illnesses are frequent as well in India, for example, 23% of women report health problems in the first months after delivery (31). Some of these problems are temporary but others become chronic. They include urinary incontinence, uterine prolapse, pain following poor repair of episiotomy Box 4.1 Obstetric fistula: surviving with dignity An obstetric fistula is a devastating yet often in silence, rather than seek medical help, even other partners launched a Global Campaign for neglected injury that occurs as a result of if such help were available. the Elimination of Fistula (27) prolonged or obstructed labour (usually This devastating condition affects more Good-quality first-level and back resuiting in a stillbirth as well). Trauma to the than two million women worldwide(21). There at childbirth prevents fistula. Once the con- vaginal wall results in an opening between are an estimated 50 000 to 100 000 additional dition has occurred it is treatable(28). The the vagina and the bladder, the vagina and cases each year (22), a figure some believe to plight of women living with fistula is e rectum, or both; this leaves the woman be an underestimate(23, 24). Most are young reminder that programmatic concerns should eaking urine and/or faeces continuously from women or adolescents. Early marriage, early go beyond simply preventing maternal deaths the vagina(16). Without surgical repair, the or repeated childbearing, along with poverty Decision-makers and professionals should be physical consequences of fistula are severe, and lack of access to quality health care in aware that the problem is not infrequent, that and include vaginal incontinence, a fetid odour, pregnancy and at birth, are the main deter- the girls and women who suffer from it nee inants (25). Fistulae occur in areas where support to get access to treatment, that enough infertility and often early mortality(16-18). access to care at childbirth is limited, or of poor trained doctors and nurses need to be available The social consequences of fistula are quality, mainly in sub-Saharan Africa and parts to provide surgical repair, and that further sup- immense: women with fistula are ostracized of southern Asia (26). In the areas where fis port is necessary for women who retum home and frequently abandoned by their husbands, tula are most often seen, few hospitals offer after treatment. Collective action can eliminate families and communities; they often become the necessary corrective surgery, which is not fistula and ensure that girls and women wh destitute and must struggle to survive (19, 20). profitable and for which surgeons and nurses suffer this devastating condition are treated so To make matters worse, many women are so are often poorly trained. In 2003, the United that they can live in dignity (29) embarrassed by this condition that they suffer Nations Population Fund along with WHO and
64 The World Health Report 2005 birth develops an infection, which needs prompt treatment so as not to become fatal or leave sequelae (14). Puerperal sepsis leads to tubal occlusion and infertility in 450 000 women per year. Hypertensive disorders of pregnancy (pre-eclampsia and eclampsia) – which are associated with high blood pressure and convulsions – are the cause of 12% of maternal deaths. They usually occur during pregnancy but also during childbirth (15). Mild preeclampsia can be monitored in pregnancy, but the transition to severe pre-eclampsia or eclampsia requires care in a hospital environment. Obstructed labour – owing to disproportion between the fetal head and the mother’s pelvis, or to malposition or malpresentation of the fetus during labour – varies in incidence: as low as 1% in some populations but up to 20% in others. It accounts for around 8% of maternal deaths globally, while the baby may be stillborn, suffer asphyxia and brain damage or die soon after birth. Skilled practitioners, such as midwives, can deal with many of these problems before labour becomes obstructed, or recognize slow progress and refer for caesarean section or instrumental delivery. Disabilities associated with obstructed labour that is dealt with late or inadequately can be very significant both for mother and child (12). For the mother the most distressing potential long-term conditions following obstructed labour are obstetric fistulae (see Box 4.1). Of the 136 million women who give birth each year, some 20 million experience pregnancy-related illness after birth (30). The list of morbidities is very diverse, ranging from fever to psychosis, and the range of care responses needed is correspondingly varied. For those women who have almost died in childbirth, recovery from organ failure, uterine rupture, fistulas and other severe complications can be long, painful and leave lasting sequelae. Other, non-life-threatening illnesses are frequent as well: in India, for example, 23% of women report health problems in the first months after delivery (31). Some of these problems are temporary but others become chronic. They include urinary incontinence, uterine prolapse, pain following poor repair of episiotomy in silence, rather than seek medical help, even if such help were available. This devastating condition affects more than two million women worldwide (21). There are an estimated 50 000 to 100 000 additional cases each year (22), a figure some believe to be an underestimate (23, 24). Most are young women or adolescents. Early marriage, early or repeated childbearing, along with poverty and lack of access to quality health care in pregnancy and at birth, are the main determinants (25). Fistulae occur in areas where access to care at childbirth is limited, or of poor quality, mainly in sub-Saharan Africa and parts of southern Asia (26). In the areas where fistulae are most often seen, few hospitals offer the necessary corrective surgery, which is not profitable and for which surgeons and nurses are often poorly trained. In 2003, the United Nations Population Fund along with WHO and An obstetric fistula is a devastating yet often neglected injury that occurs as a result of prolonged or obstructed labour (usually resulting in a stillbirth as well). Trauma to the vaginal wall results in an opening between the vagina and the bladder, the vagina and the rectum, or both; this leaves the woman leaking urine and/or faeces continuously from the vagina (16). Without surgical repair, the physical consequences of fistula are severe, and include vaginal incontinence, a fetid odour, frequent pelvic and/or urinary infections, pain, infertility and often early mortality (16–18). The social consequences of fistula are immense: women with fistula are ostracized and frequently abandoned by their husbands, families and communities; they often become destitute and must struggle to survive (19, 20). To make matters worse, many women are so embarrassed by this condition that they suffer other partners launched a Global Campaign for the Elimination of Fistula (27). Good-quality first-level and back-up care at childbirth prevents fistula. Once the condition has occurred it is treatable (28). The plight of women living with fistula is a powerful reminder that programmatic concerns should go beyond simply preventing maternal deaths. Decision-makers and professionals should be aware that the problem is not infrequent, that the girls and women who suffer from it need support to get access to treatment, that enough trained doctors and nurses need to be available to provide surgical repair, and that further support is necessary for women who return home after treatment. Collective action can eliminate fistula and ensure that girls and women who suffer this devastating condition are treated so that they can live in dignity (29). Box 4.1 Obstetric fistula: surviving with dignity