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Maternal mortality remains a global tragedy. Every
minute a woman dies of pregnancy related consequences. 99% of these
deaths occur in the developing world. The 5 most common causes
of maternal mortality in the developing world would not lead to
death if treatment was provided in time. Simple and inexpensive
medical technology to
prevent or treat these complications has been available for over
half a century.
The main causes of maternal mortality in women are Haemorrhage,
Sepsis, Eclampsia, Unsafe Abortion and Obstructed Labour.
• Haemorrhage accounts for a quarter of all maternal
death. A woman, even in good health, who haemorrhages just after giving birth
can die within two hours, especially if she is left without obstetric care.
Haemorrhage can be prevented and treated using medications such as oxytocin.
• Septicaemia, or general infection, is the main cause
of death after delivery. WHO estimates that 76,000 women, or 15%,
die of this type of infection, particularly in developing countries. One in
20 women giving birth develops an infection requiring antibiotics to avoid
potential fatalities.
• Eclampsia is the world’s third most
common cause of maternal mortality. This is linked to hypertension
and happens at the end of pregnancy. It can lead to seizures, coma
and death. According to the WHO, there are approximately 70,000
cases of eclampsia each year in the 143 least developed countries
in the world. Convulsions related to eclampsia can be prevented
and treated using the drug Magnesium Sulfate.
• Unsafe abortion, refers to the termination of an unintended
pregnancy either by persons lacking the necessary skills or in
an unhygienic environment or both. It is responsible for 13% of
all maternal mortality or 68,000 deaths each year.
At an international level, unsafe abortion has been recognised
as a public health problem. The figures speak for themselves: according
to the WHO, of the 200 million pregnancies which are registered
every year, around 46 million are terminated, and only 60% are
done so in safe medical conditions. In other words, there are over
18 million unsafe abortions every year.
As a result, one woman dies every six minutes from unsafe abortion.
Of those who live, many suffer serious consequences such as infertility
or complications with future pregnancies.
MSF medical teams all too often see women who are haemorrhaging,
or have infections or injuries (to the uterus or elsewhere) from
unsafe abortions.
Comprehensive sexual and reproductive health care
services can greatly reduce the number of unsafe abortions by offering
safer alternatives through family planning and by identifying and
treating complications during pregnancy early on.
• Obstructed labour (dystocia) is another
leading cause of death and infirmity, particularly in Sub-Saharan
Africa and South-East Asia. It can also cause rupture between the
vagina-bladder wall and/or the vagina-rectum wall (obstetric fistula).
On a worldwide level, it is estimated that 5% of pregnancies result
in obstructed labour, leading to 8% of maternal deaths. Obstructed
labour can be managed if it is identified early by following correctly
a woman in labour and intervening with drugs like oxytocin at the
appropriate moment. Interventional deliveries such as vacuum, forceps
or caesarean sections can likewise prevent significant death and
disability resulting from prolonged obstructed labour.
The pathologies that kill women during their pregnancies, deliveries
or just after birth are the same throughout the world. What makes
the difference is access to quality health care. It is simply the
availability of affordable and effective treatment in developed
countries that prevents these conditions which continue to kill
pregnant women in developing settings.
"To prevent this death and suffering , all that women need
is the supervision of trained medical staff during pregnancy and
delivery, and access to emergency medical care in the event of
complications," explains Christine Lebrun, Head of Reproductive
Health Programmes at MSF.
Yet, whilst the global percentage of deliveries assisted by qualified
staff worldwide is 61%, this drops to 34% in less developed countries.
This is even less in Somalia and Ethiopia (23%) and worst in Haiti
(5.6%).
It is worth noting that in many countries and for a multitude
of reasons, women deliver at home. In fact, only 40% of deliveries
worldwide take place in medical structures. And in the countries
where home-birth is most common, maternal mortality is the highest.
As MSF is often the only health provider in a region, women frequently
have to travel long distances to reach us, and they may not commence
this journey until complications have already developed. In Ituri,
for example, (in the east of the Democratic Republic of the Congo),
more than one third of the 200 deliveries taking place each month
in the maternity ward of the Bon Marché hospital present
with complications such as haemorrhage or eclampsia.
This is also the case in Malakand, a remote rural area in Pakistan’s
north-west province on the border with Afghanistan. Here MSF has
observed delays in the decision to consult a health facility, which
is first of all up to the traditional midwife and then the husband.
Then there are the distances involved in reaching a health centre
in this mountainous, isolated area, and the lack of available transport.
Finally, the lack of quality care dispensed in certain public structures
adds still further to the delays in providing care to meet women’s
needs.
MSF has made the reduction of maternal mortality and morbidity
one of its operational priorities, implementing effective strategies
for improving the presence of trained staff during deliveries,
ensuring the accessibility of quality emergency obstetric care
and encouraging women to deliver in health facilities.
The efforts deployed to remedy the 'three delays' (delay in seeking
care, delay in reaching a health facility and delay in quality
care) are often decisive in saving the lives of both mother and
child. MSF has introduced mobile clinics combined with referral
systems, to identify women presenting complications and transfer
them when necessary to a health post or hospital where they can
receive appropriate care. These can be seen in the Ivory Coast,
Pakistan, the Central African Republic and Burundi.
The models used by MSF to tackle maternal mortality and disability
take into account all aspects of reproductive health. These models
are already being put into practice in 20 MSF countries, and involve
around 30 qualified national and expatriate midwives. In more than
half its projects, the Belgian section offers at least one reproductive
and/or sexual health service, which focus on women and their needs.
MSF’s priorities for reducing maternal and infant
mortality are:
• Care during pregnancy and prenatal consultations improves
the mother’s health during her pregnancy and encourages foetal
development. The number of stillbirths is thereby reduced. In 2006,
MSF teams carried out more than 450,000 prenatal consultation in
various countries.
"We work on the principal that all pregnancies can be a risk. The prenatal
consultations are therefore important for detecting and treating
pregnant women’s
health problems. We also give them health advice. The consultations
provide an occasion to inform women and their families about complications
that can arise during delivery, helping them prepare for emergencies and identify
a health structure where they can go without delay for delivery." Christine
Lebrun, Head of Reproductive Health Programmes at
MSF.
• Emergency obstetric care administered by qualified
staff capable of handling a complicated delivery can be a question
of life and death for women experiencing complications during delivery or just
after.
"If we want to avoid women continuing to die during delivery, it is essential
to provide them with access to emergency obstetric care. For MSF,
it is therefore a priority to provide this service in its programmes
in order to reduce maternal mortality. We provide access to emergency obstetric
care in most of our health facilities where we can treat or prevent the complications
mentioned above. Where appropriate we also try to provide comprehensive
emergency obstetric care, which includes caesarean sections or blood transfusions.
Where this is not possible we try to ensure the possibility of rapid transfer
to other quality health care facilities." Christine Lebrun, Head of Reproductive
Health Programmes at MSF.
One of MSF’s challenges can lie in encouraging the people
we assist to make use of our emergency obstetric services. This
requires locating services close to the people that need them,
adapting them to local cultures and making them free of charge
as our beneficiaries are often amongst the poorest sector of the
population and cannot afford to pay for health care.
During the year 2006, MSF carried out 90,000 deliveries around
the world.
Working in collaboration with traditional birthing attendants
in order to provide access to health services for women in general,
and to obstetric health care in particular is sometimes key. "Traditional
birthing attendants are a key actor in the field of women’s
health, because they are the first ones to be in contact with pregnant
women," explains Christine Lebrun, Head of Reproductive Health
Programmes at MSF. "Given their influence within communities,
they can play an important role in encouraging women to have their
pregnancies followed up in qualified health facilities as well
as opening up access to emergency obstetric services by transferring
women to our structures to deliver with skilled attendants."
• Postnatal care
Most maternal mortality and morbidity occurs after delivery, often
from haemorrhage or septicaemia. This is almost the most dangerous
period for the child with 30% of children’s deaths occurring
in the first 4 weeks of life. The majority in the first few days
after delivery. Postnatal care is important for ensuring the good
physical and mental health of both the mother and child.
• Access
to contraception and family planning services
This focuses on limiting the number of unwanted pregnancies and
thereby helps reduce the number of clandestine abortions. Contraception
and family planning can also prevent mother to child transmission
of HIV/AIDS, and reduce the risk of malnutrition. The WHO estimates
that if women not wanting children used effective means of contraception,
up to 100,000 maternal deaths could be avoided per year.
"MSF generally includes family planning services in all its primary health
care programmes, adapting them to the local culture. Family planning
should enable women, and men, to decide if they want to have children,
when they want to have them, and how many. It also limits the number of clandestine
abortions resulting from non-desired pregnancies, thereby reducing maternal
mortality." Christine Lebrun, Head of Reproductive Health
Programmes at MSF.
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AN ADDITIONAL THREAT: MALARIA DURING PREGNANCY
"A pregnant woman is particularly vulnerable to malaria," explains
Michel Van Herp, an MSF epidemiologist. "In most endemic areas,
pregnant women are the adult group most vulnerable to the disease.
Their immunity is weakened, above all at the end of the pregnancy,
rendering them more sensitive to infection and increasing the risks
of the disease such as severe anaemia and death."
For the baby, maternal malaria increases the risk of spontaneous
abortion, perinatal mortality, premature birth and low birth weight
(one of the major causes of infant death).
According to the WHO, around 10,000 women live in countries with
endemic malaria and 200,000 newborns die from the disease each
year. Most deaths occur in countries with plasmodium falciparum
malaria. This is the most dangerous form of the disease, and the
most prevalent in Africa.
Maternal malaria is also associated with an increased risk of
transmission of HIV from the mother to the child whilst in utero.
MSF focuses on the prevention and case management of malaria during
pregnancy in the numerous countries where malaria constitutes a
threat to both pregnant women and their unborn children.
In low endemic malarial regions, such as Karuzi
province in the high plateaus of Burundi, pregnant women have not
acquired a high level of immunity and generally fall ill as soon
as they are infected. MSF adopts a three-pronged approach here.
"During prenatal consultations MSF distributes impregnated
mosquito nets so pregnant women and their newborns can sleep protected
from mosquitoes," explains Dr Betrand Draguez, head of MSF’s
medical programmes in Burundi.
When national protocols allow, MSF also administers preventive
treatment to pregnant women, with each woman receiving two doses
of anti-malarial medicine whilst coming in for regular prenatal
consultations.
There is also a need for the efficient case management of the
disease itself for those who are infected, involving treatment
with anti-malarial medicines that can be administered effectively,
and are harmless during pregnancy.
In high or moderate endemic malaria areas, the
biggest challenge in case management is that most adult women have
developed some immunity to the disease, so that even if they are
infected during the pregnancy, they do not necessarily develop
clinical symptoms. MSF promotes routine blood testing at each antenatal
consultation for these patients in order to diagnose malaria even
when they may be asymptomatic.
In a country with high endemic malaria, such as Sierra Leone,
MSF has developed a malaria programme especially for pregnant women
and children under 5 years. The programme focuses on prevention
(by the distribution of mosquito nets impregnated with insecticide),
diagnosis and treatment of malaria. These different services are
offered to pregnant women for free. MSF has also set up an outreach
anti-malarial programme in order to reach women and children incapable
of reaching MSF health facilities (or any other sufficiently close
health care centre).
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According to the WHO, female genital mutilation is the cutting,
or partial or total removal, of the external female genitalia for
cultural, religious, or other non-medical reasons.
The immediate and long-term health consequences of female genital
mutilation vary according to the type and gravity of the procedure.
For instance haemorrhaging or septicaemia may be more or less immediate
whereas HIV transmission resulting from using an infected instrument
may have longer term effects.
According to the latest report from the WHO, women who have undergone
the most severe form of female genital mutilation run noticeably
higher risks of having complicated deliveries and their babies
are more likely to die. Infibulation can cause prolonged labour,
leading to heavy bleeding, fistulas, and a need for caesarean section
as well as newborn distress and death. It may also impact on the
ability of the attendant to follow the labour and increase the
risk of urinary tract infections.
MSF is opposed to the practice of female genital mutilation of
any sort because of the harmful medical consequences it has on
women’s health, and the lack of respect for human rights
it presents. MSF takes part in no aspect of this practice, and
does not supply safe and secure equipment. On the other hand,
we of course provide care for women suffering the medical consequences
of this practice.
For instance, to alleviate the risk of complications during pregnancy
for women who have undergone infibulation, it is necessary to unstitch
the vaginal opening so that the infant can pass through (disinfibulation)
MSF has a policy of refusing to stitch the genital lips back together
(reinfibulation) and MSF teams explain to communities the medical
reasons for this.
In Port Sudan, MSF runs a pilot programme in an area where FGM
is prevalent and through the help of women’s networks has
made its policy on reinfibulation well known.
Although this policy of refusing to reinfibulation follows national
regulations, cultural opposition can make it difficult to implement.
Zainab Osman, who supervises MSF’s home visits programme,
recalls: "In the beginning, when women learnt that reinfubulation
was not practiced at the hospital where MSF worked, they simply
refused to go there for their deliveries. We had to make a big
effort to explain to the members of our community that it is just
not right that a woman has to suffer and die due to genital mutilation.
Our efforts have borne fruit and women are coming to the hospital
in increasing numbers".
In Port Sudan today MSF registers more than 300 prenatal consultations
and around 25 deliveries every week.
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