attending to 136 million births, every year 65 and perineal tears, nutritional deficiencies, depression and puerperal psychosis, and mastitis (32)(see Box 4.2). Even less is known about these morbidities than about maternal deaths. They are difficult to quantify, owing to problems with definitions and inadequate records (33). More and more reliable information on the whole range of morbidities would be an important step towards better planning of services and improved care around childbirth. SKILLED PROFESSIONAL CARE. AT BIRTH AND AFTERWARDS 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 as complications are largely unpredictable and may rapidly become life-threatening (34, 35). Both maternal and neonatal mortality are lower in countries where mothers giv- ing birth get skilled professional care, with the equipment, drugs and other supplies needed for the effective and timely management of complications (10, 34). The history of successes and failures in reducing maternal mortality(including in industrialized countries)shows that this is not a spurious statistical association(3, 36). Reversals in maternal and neonatal mortality in countries where health systems have broken down provide further confirmation that care matters Successes and reversals: a matter of building health systems Industrialized countries halved their maternal mortality in the early 20th century by providing professional midwifery care at childbirth; they further reduced it to current historical lows by improving access to hospitals after the Second World War (37 ). Quite a number of developing countries have gone the same way over the last few decades 3). One of the earliest and best-documented examples is Sri Lanka, where maternal Box 4.2 Maternal depression affects both mothers and children Women are between two and three times more unwanted pregnancy; ndent of other risk factors. the infants and ikely to experience depression and anxiety than poor relationship with a partner, including children of mothers who are depressed, espe infants and young children are more vulnerable. providing insufficient practical or emotional have significantly lower birth weight, are mor Depression in women during pregnancy and pport, having little involvement in infant than twice as likely to be underweight at age six in the year after birth has been reported in all care, holding traditional rigid sex role months, are three times more likely to be short cultures. Rates vary considerably, but average expectations, or being coercive or violent; age at six months, have significantly poorer about 10-15% in industrialized countries. lack of practical and emotional support, or long-term cognitive development, have higher Contrary to what was previously thought, even criticism from mother or mother-in-law, tes of antisocial behaviour, hyperactivity and higher rates are reported from developing insufficient social support, including absence attention difficulties, and more frequently expe countries. This contributes substantially to of attachment to a peer group, few confiding rience emotional problems. maternal mortality and morbidity Parasuicide relationships and lack of assistance in Effective psychological and pharmacological thoughts of suicide or actual self-harm- crises treatment strategies for depression exist. In occurs in up to 20% of mothers in developing poverty and social adversity, including industrialized countries less than half of the countries. It is associated with entrapment crowded living conditions and lack of mothers who would benefit from such treat- intolerable situations such as unwanted employment ment receive it. The situation is much worse pregnancy(particularly in young single previous personal history of depression or in the developing countries where care may be women), forced displacement as a refugee, or ast psychiatric hospitalization available to only 5% of women. It is important intractable poverty. Suicide is a leading cause persistent poor physical health hat maternal, newborn and child health pi of maternal mortality in countries as diverse as coincidental adverse life events, such as the grammes recognize the importance of these Many factors contribute to maternal depres- Maternal depression has serious physical and health workers for recognizing, assessing and sion during pregnancy and after birth, including: psychological consequences for children. Inde- treating mothers with depression
attending to 136 million births, every year 65 and perineal tears, nutritional deficiencies, depression and puerperal psychosis, and mastitis (32) (see Box 4.2). Even less is known about these morbidities than about maternal deaths. They are difficult to quantify, owing to problems with definitions and inadequate records (33). More and more reliable information on the whole range of morbidities would be an important step towards better planning of services and improved care around childbirth. SKILLED PROFESSIONAL CARE: AT BIRTH AND AFTERWARDS 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, as complications are largely unpredictable and may rapidly become life-threatening (34, 35). Both maternal and neonatal mortality are lower in countries where mothers giving birth get skilled professional care, with the equipment, drugs and other supplies needed for the effective and timely management of complications (10, 34). The history of successes and failures in reducing maternal mortality (including in industrialized countries) shows that this is not a spurious statistical association (3, 36). Reversals in maternal and neonatal mortality in countries where health systems have broken down provide further confirmation that care matters. Successes and reversals: a matter of building health systems Industrialized countries halved their maternal mortality in the early 20th century by providing professional midwifery care at childbirth; they further reduced it to current historical lows by improving access to hospitals after the Second World War (37). Quite a number of developing countries have gone the same way over the last few decades (3). One of the earliest and best-documented examples is Sri Lanka, where maternal 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 • unwanted pregnancy; • poor relationship with a partner, including his being unavailable during the baby’s birth, providing insufficient practical or emotional support, having little involvement in infant care, holding traditional rigid sex role expectations, or being coercive or violent; • lack of practical and emotional support, or criticism from mother or mother-in-law; • insufficient social support, including absence of attachment to a peer group, few confiding relationships and lack of assistance in crises; • poverty and social adversity, including crowded living conditions and lack of employment; • previous personal history of depression or past psychiatric hospitalization; • persistent poor physical health; • coincidental adverse life events, such as the loss of a partner. Maternal depression has serious physical and psychological consequences for children. IndeWomen are between two and three times more likely to experience depression and anxiety than men. Mothers who are pregnant or caring for infants and young children are more vulnerable. Depression in women during pregnancy and in the year after birth has been reported in all cultures. Rates vary considerably, but average about 10–15% in industrialized countries. Contrary to what was previously thought, even higher rates are reported from developing countries. This contributes substantially to maternal mortality and morbidity. Parasuicide – thoughts of suicide or actual self-harm – occurs in up to 20% of mothers in developing countries. It is associated with entrapment in intolerable situations such as unwanted pregnancy (particularly in young single women), forced displacement as a refugee, or intractable poverty. Suicide is a leading cause of maternal mortality in countries as diverse as the United Kingdom and Vietnam. Many factors contribute to maternal depression during pregnancy and after birth, including: pendent of other risk factors, the infants and children of mothers who are depressed, especially those experiencing social disadvantage, have significantly lower birth weight, are more than twice as likely to be underweight at age six months, are three times more likely to be short for age at six months, have significantly poorer long-term cognitive development, have higher rates of antisocial behaviour, hyperactivity and attention difficulties, and more frequently experience emotional problems. Effective psychological and pharmacological treatment strategies for depression exist. In industrialized countries less than half of the mothers who would benefit from such treatment receive it. The situation is much worse in the developing countries where care may be available to only 5% of women. It is important that maternal, newborn and child health programmes recognize the importance of these problems and provide support and training to health workers for recognizing, assessing and treating mothers with depression. Box 4.2 Maternal depression affects both mothers and children
66 The World Health Report 2005 mortality levels, compounded by malaria, had remained well above 1500 per 100 000 births in the first half of the 20th century-despite 20 years of antenatal care. In this period midwifery was professionalized, but access remained limited. From around 1947 mortality ratios started to drop closely following improved access and the de velopment of health care facilities in the country (38) This brought mortality ratios down to between 80 and 100 per 100000 births by 1975. Improved management and quality then further lowered them to below 30 in the 1990s, according to Ministry of Health time series (36). Malaysia also has a long-standing tradition of professional midwifery-since 1923 Maternal mortality was reduced from more than 500 per 100 000 births in the early 1950s to around 250 in 1960. The country then gradually improved survival of mothers and newborns further by introducing a matemal and child health programme. a dis trict health care system was introduced and midwifery care was stepped up through a network of "low-risk delivery centres, backed up by high-quality referral care, all with close and intensive quality assurance and on the initiative of the public sector authorities. This brought maternal mortality to below 100 per 100 000 by around 1975, pe Until the 1960s Thailand had maternal mortality levels well above 400 per 100 births, the equivalent of those in the United Kingdom in 1900 or the USA in During the 1960s traditional birth attendants were gradually substituted by certi fied village midwives, 7191 of whom were newly registered within a 10-year period mortality came down to between 200 and 250 per 100 000 births. During the 1970s Figure 4.2 Maternal mortality since the 1960s in Malaysia, Sri Lanka and Thailand 400 Thailand Sri Lanka Malaysia 64666870 808284868890 7200 new midwife 8 814 new midwife registrations registrations Capacity of communty. Shift to births in hospital in hospital Rural health services Skilled attendance from 70% to 90% TBAS replaced by skilled attendants shift to births in hospital
66 The World Health Report 2005 mortality levels, compounded by malaria, had remained well above 1500 per 100 000 births in the first half of the 20th century – despite 20 years of antenatal care. In this period midwifery was professionalized, but access remained limited. From around 1947 mortality ratios started to drop, closely following improved access and the development of health care facilities in the country (38). This brought mortality ratios down to between 80 and 100 per 100 000 births by 1975. Improved management and quality then further lowered them to below 30 in the 1990s, according to Ministry of Health time series (36). Malaysia also has a long-standing tradition of professional midwifery – since 1923. Maternal mortality was reduced from more than 500 per 100 000 births in the early 1950s to around 250 in 1960. The country then gradually improved survival of mothers and newborns further by introducing a maternal and child health programme. A district health care system was introduced and midwifery care was stepped up through a network of “low-risk delivery centres”, backed up by high-quality referral care, all with close and intensive quality assurance and on the initiative of the public sector authorities. This brought maternal mortality to below 100 per 100 000 by around 1975, and then to below 50 per 100 000 by the 1980s (36, 39, 40). Until the 1960s Thailand had maternal mortality levels well above 400 per 100 000 births, the equivalent of those in the United Kingdom in 1900 or the USA in 1939. During the 1960s traditional birth attendants were gradually substituted by certi- fied village midwives, 7191 of whom were newly registered within a 10-year period: mortality came down to between 200 and 250 per 100 000 births. During the 1970s Maternal mortality ratio per 100 000 live births 1960 Thailand 450 Figure 4.2 Maternal mortality since the 1960s in Malaysia, Sri Lanka and Thailand Sri Lanka Malaysia 400 350 300 250 200 150 100 50 0 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 7200 new midwife registrations 18 814 new midwife registrations Shift to births Capacity of community in hospital hospitals quadrupled Increased access to public sector midwives Shift to births in hospital Quality improvement Rural health services TBAs replaced by skilled attendants Skilled attendance from 70% to 90% Shift to births in hospitals Source: (3)