May 10, 2008

Rabail Baig stresses on the need to tackle the issue of maternal mortality through various direct and indirect measures

Statistics say that over 380 women become pregnant every minute and nearly 200 face unplanned or unwanted pregnancy. Over 100 women experience a pregnancy-related complication, around 40 of them have an unsafe abortion, and every minute, a newborn child loses its mother before it opens its eyes into the world.

Nearly every 60 seconds, one woman dies from the complications of pregnancy and childbirth. Translated in numbers, this is more than 500,000 women dying each year. If this is not scary enough, 99 per cent of these deaths occur in the developing world.

As the world honours mothers by celebrating Mother’s Day in May every year, there are mothers out there who are neither the part of the celebration nor healthy. They are fighting with not one, but two lives: their own and that of their unborn child. According to the World Health Organisation estimates, in the year 2000 alone, more than a half million women died from causes related to pregnancy or childbirth. In the same year, the UN estimated global maternal mortality at 529,000, of which less than one per cent occurred in the developed world.

What is heart-wrenching is the fact that most of these deaths have been medically preventable for decades since treatments to avoid such deaths have been well-known since the 1950s and reducing mother mortality is one of the UN’s eight Millennium Development Goals. In spite of that, the average maternal mortality ratio worsens by the year.

Maternal mortality varies widely in the world’s regions. Maternal Mortality Ratio or MMR is the ratio of the number of maternal deaths per 100,000 live births. The MMR is used as a measure of the quality of a healthcare system. Sierra Leone in Africa has the highest maternal death rate at 2,000, and Afghanistan comes close second at 1,900 maternal deaths per 100,000 live births, as reported by the UN based on the figures of the year 2000. One can only imagine the situation and statistics as they must be eight years later.

The ‘lifetime risk of maternal death’ accounts for the number of pregnancies at risk. In sub-Saharan Africa, the lifetime risk of maternal death is 1 in 16; for the developed nations only 1 in 2,800.

Maternal mortality is a sentinel event to assess the quality of a healthcare system. However, a number of issues need to be recognised. For example, cases with ‘incidental causes’ include deaths secondary to violence against women that may be related to the pregnancy and be affected by the socioeconomic and cultural environment. Also, it has been reported that about 10 per cent of maternal deaths may occur late, that is after 42 days after a termination or delivery. Further, it is well-recognised that maternal mortality numbers are often significantly underreported.

The major causes of maternal death are bacterial infection; toxemia or the presence of toxins in the blood, obstetrical haemorrhage or heavy bleeding during pregnancy, labour, or the puerperium, the time period after childbirth; ectopic or tubal pregnancy where an embryo is implanted elsewhere than the uterus; puerperal sepsis or puerperal fever also called childbed fever; amniotic fluid embolism where amniotic fluid, foetal cells, hair or other debris enters the mother’s blood stream via the placental bed of the uterus and triggers an allergic reaction, and various complications of abortions.

What also needs to be addressed is that high rates of maternal deaths occur in the same countries that have high rates of infant mortality which reflects generally poor nutrition and medical care. Low birth weight of the child increases the risk of maternal death from cardiovascular disease. Subtracting one pound of infant birth weight doubles the risk of maternal death. Therefore, the heavier the birth weight of the child, the lower the risk of maternal death.

For many women in Pakistan’s remote provinces, giving birth can be fatal. A number of husbands lose their wives as they try to give birth to their sixth, 10th or even 12th child.

Many rural women in Pakistan give birth to an average of five children by the time they are in their mid-20s, and endure the tragedies of multiple miscarriages and stillbirths. Due to illiteracy and lack of awareness about their own bodies, at times they themselves refuse to see the doctor and, at times it is under family pressure that they refrain from voicing out their gynaecological problems. They rely on self-medication or on the advice and prescriptions of local pharmacists or chemists, which only makes matters worse for them. The level of hygiene adds to their problems. As a result, the MMR in Pakistan is 500 per 100,000 births. The numbers may not come out as horrifying as the fact that children who are left motherless are three to 10 times more likely to die within two years of their birth.

Maternal death and disability is a tragedy that has no single cause or solution. The contributing factors include the difficulty of predicting and/or preventing obstetric complications, the lack of access to good quality maternal health services, poor health before and during pregnancy and women’s low social and economic status. Lack of access to family planning is also a major factor behind 76 million unintended pregnancies every year in countries like Pakistan.

Ninety-nine per cent of unsafe abortions carried out each year, take place in developing countries, out of which approximately 890,000 induced abortions per year are carried out in Pakistan. It is estimated that on an average, every Pakistani woman would experience abortion at least once in her lifetime, and there is absolutely no guarantee that it would be safe. Only four to seven per cent of women go to trained service providers for matters related to abortion fertility and advice and consultation on the use of contraceptives. The total fertility rate in Pakistan is four children per woman. There is a wide gap between knowledge (97 per cent) and use of contraceptives (28 per cent) among currently married women.

However, all is not lost. A life-cycle approach to women’s health anticipates and meets women’s health needs from infancy through old age. It emphasises health-seeking behaviour and appropriate services to meet women’s health needs throughout their lives, also recognising the right of all women to make informed decisions about their health.

Women and girls have special health needs throughout their lives and health systems in developing countries should recognise and address women’s health problems throughout the life-cycle.

Actions, both positive and negative, taken at any stage in a woman’s life can and will affect her throughout her life. For example, exclusive breastfeeding during the first four to six months provides infants with the antibodies and nourishment needed to begin a healthy life. A woman who develops a reproductive tract infection and does not receive appropriate treatment can become infertile. Girls fed inadequately during childhood may have stunted growth, leading to higher risk of obstructed labour.

The life-cycle approach for health systems means that the reproductive health services must address the specific and often-neglected health needs of young girls, adolescents, and women in their post-reproductive years. For adolescent or teenaged girls, there is a dire need to promote adequate nutrition, ensure equal access to information and education about sexuality and reproduction and protect them from harmful traditional practices. As for post-reproductive aged women, it is important to encourage them to continue seeking healthcare throughout their menopausal and post-menopausal years. The provision of screening and accessible treatment for breast and gynaecological cancers and uterine prolapse is also vital.

Socio-economic status has significant impact on women’s health throughout their lives and, therefore, women are more likely than men to be poor, less educated, of lower social status, burdened with heavy work from an early age and fall victim to domestic and sexual violence. Most women have special health needs, limited access to health services, and little sense of entitlement to healthcare.

Actions to improve women’s education, economic status, and legal rights are essential to improving the quality of women’s health and lives. Providing women with seven or more years of education can significantly improve their health and that of their families. Women who have had more than seven years of schooling are more likely to use contraception to control their fertility, have fewer and healthier children, seek healthcare for themselves and their children, and use medication properly.

Ours is a man’s world, and there are many positive roles for men to play throughout women’s life-cycle according to the approach.

Men, as family and community members, have vital roles to play in promoting women’s rights and health by learning to communicate effectively and openly with women, especially sexual partners, ensuring that their daughters have access to education, providing economic and emotional support for partners during and after pregnancy, taking an active role in preventing unwanted pregnancies and preventing transmission of sexually transmitted infections or STIs and HIV and Aids. Educating young men about responsible sexuality, promoting gender equality in the household and community and preventing and condemning violence against women can also contribute largely to the betterment of women in general and mothers in particular.

The decline in maternal deaths can be largely improved through asepsis, or by preventing the introduction of organisms that cause infection, the use of caesarean section, fluid management and blood transfusion, and better prenatal care. To reduce maternal mortality, we need to invest more in health systems in order to improve the quality and coverage of delivery services and to provide prenatal and postnatal care for the poor. The proportion of births attended by skilled personnel also helps to track progress in reducing maternal mortality. Health workers with midwifery skills are the key to reducing maternal mortality. As well as attending births, they provide mothers with basic information about prenatal and postnatal care for themselves and their children. Improving women’s social status and ensuring gender equity in healthcare are important in achieving this goal.

Despite their low incomes, China, Cuba and Sri Lanka have all reduced maternal deaths through efforts to improve access to primary healthcare, strengthen health systems and improve the quality of healthcare.

In the Pakistani context, training of community-based providers about essential emergency obstetric care is vital. The government should provide training about essential emergency obstetric care and lifesaving skills to village midwives, community health centre midwives and paramedics who are likely to attend births. Emergency obstetric care should involve treating symptoms of ‘shock,’ giving injections including antibiotics and sedatives, and performing manual extraction of the placenta and simple curettage.

Many rural women in Pakistan give birth to an average of five children by the time they are in their mid-20s. Due to illiteracy and lack of awareness about their own bodies, at times they themselves refuse to see the doctor and, at times, it is under family pressure that they refrain from reporting their gynaecological problems.

Training in lifesaving skills should include pre- and post-evaluation of skills. Training of hospital-based providers about lifesaving skills and provision of essential comprehensive obstetric care is also significant. Hospital midwives and nurses should be trained to administer blood and blood product transfusions and provide other comprehensive emergency obstetric services without delay. Also, general practitioners should be trained to manage postpartum haemorrhage and perform appropriate surgery. They should also be trained to treat various complications and to manage prolonged labour, malpresentations, and neonatal emergencies.

The training of midwives and hospital personnel to emphasise hygiene and the quality of care is absolutely essential. These healthcare providers should be trained to improve communication with clients and to better educate clients about signs of danger during pregnancy and delivery. Supervisors must also support, guide, train, and assist medical staff to identify and solve problems. Meanwhile, clear job descriptions for staff should be accompanied by checklists to help supervisors monitor performance. Supervision should rely more on close and direct observation of staff activities. Supervisory responsibilities should include not only ensuring quality care, but also making available appropriate training and information, education, and communication materials, as well as medical supplies and equipment.

Community-based information and education efforts should emphasise the potential risk of obstetric complications for all pregnant women and the need for individuals and family members to recognise danger signs. It is obvious that the primary cause of delay in obtaining adequate care is failure to recognise danger signs, or the tendency to seek treatment from traditional healers whose methods are of little or no efficacy and in many cases may exacerbate a bad situation. The key to overcoming this situation is to educate the community to understand the risks and danger signs of pregnancy and delivery, and to mobilise them to obtain appropriate care more quickly.

Of rights and reservations

Reproductive health is a state of complete physical, psychological, and social well-being and not merely the non-existence of disease or medical condition, in all matters related to the reproductive system and to its functions and processes. Sexual health means having a responsible, satisfying, and safe sex life, that is free from disease, injury, violence, disability, unnecessary pain, or risk of death.

Sexual and reproductive rights have their own distinguishing characteristics. While reproductive rights include the rights of couples and individuals to make free and informed decisions about their reproductive lives, including the number, timing, and spacing of their children, and attain the highest standard of sexual and reproductive health, sexual rights include the rights of all individuals to make free and informed decisions on all matters relating to their own sexuality and be free of discrimination, coercion, or violence in their sexual lives.

Women’s health is directly related to their status in society. A rights-based approach to sexual and reproductive health to improve maternal mortality rates is vital in this scenario. The International Conference on Population and Development (ICPD) affirmed that women and men have the right to the highest standards of sexual and reproductive health services and information. The conference aims to bring together researchers, scientists, engineers and scholar students to exchange and share their experiences, new ideas, and research results about all aspects of population and development, and discuss the practical challenges encountered and the solutions adopted.

The rights-based approach focuses mainly on the health and well-being of mothers, at the same time recognising the importance of gender equity and equality. It builds on the existing international human rights agreements on essential health services to ensure sexual and reproductive rights, information and counselling on human sexuality, reproductive health, and parenthood, family planning, prenatal, postnatal and delivery care, health care for infants, safe abortion, management of abortion-related complications, prevention and treatment of infertility and sexually transmitted infections and reproductive tract infections.

World Population Foundation deals with the issues of sexual and reproductive health and rights including safe motherhood. Cyma Ashraf, Programme Manager SRHR, World Population Foundation says, “From the rights-based approach, we have a strong belief that to reach the targets of Millennium Development Goals of Gender Equality and Equity and Reduced Maternal Mortality Ratio(MMR) by 2015, it is important to have plans, processes and policies, according to the standards and principles of the international human rights system, which clearly reflect and express linkage to rights, accountability, empowerment, participation and non-discrimination and attention to vulnerable group.”

According to Ashraf, if additional services such as diagnosis and treatment of reproductive system cancers and HIV and Aids are not offered, a system should be in place to provide referrals to these services. Client-centred care emphasises on free and informed consent and respect for clients’ rights and needs. Comprehensive care addresses the full range of sexual and reproductive health needs and provides referrals when appropriate.

The government of Pakistan can also step up and protect and promote sexual and reproductive health and rights by reviewing all laws, policies, and practices, and changing those that inhibit the full exercise of these rights. It is essential to enforce gender-sensitive laws and policies through active implementation and monitoring mechanisms and strengthen health infrastructures to make comprehensive services more widely available, and give priority to financing for sexual and reproductive healthcare.

“It is also vital that programmes on ‘safe motherhood’ focus on a life-cycle approach since actions, both positive and negative, taken at any stage in a woman’s life can and will affect her throughout her life,” adds Ashraf. “Reproductive health services must address the specific and often-neglected health needs of young girls, adolescents, and women in their post-reproductive years by promoting the awareness on adequate nutrition, access to information for young girls and encouraging women to seek health care throughout their menopausal and post-menopausal years for screening and accessible treatment for breast and gynaecological cancers and uterine prolapse.” she says.

                                                                                                                                                  — R.B.