Journal Perinatal Medicine 2003; 31(5):386-91
Of all health statistics mentioned by World Health Organization (WHO), maternal mortality is the unique one showing the largest discrepancy between developed and developing countries. Approximately 90% of maternal deaths (more than 0.5 million) occur in developing countries each year.
During the last century, almost all countries have accepted antenatal care principles. However, insufficiency of the resources and lack of women’s compliance were the main handicaps in developing countries compelling these countries to apply various standard programs. Unfortunately, these programs are not effective enough in preventing and treating maternal mortality. Both fixing the number (quantity) of antenatal visits and static approach affect the “quality” of antenatal care.
Bleeding, chronic anemia, hypertensive disorders, obstructed labor, unsafe abortions and infections are the main affecting factors in maternal mortality. The majority of these factors are preventable. It is important to suspect any of these factors and to perform prompt interventions during antenatal care, and immediately after delivery. The way reaching this solution is to realize evidence-based approach.
Antenatal care is a concept extending from pre pregnancy to postpartum, leading to effective emergency care for unpredictable and predictable complications during pregnancy and childbirth. Worldwide policies are not always available for each country, coercing national policies. There is still need to prospective randomized trials to clarify this concept and relevant policies.
Key words: Developing countries, Maternal mortality
Prenatal care in many countries today is not based on good economics or evidence based scientific proof. Local, professional and traditional habits, political motives, cultural and ethical misbeliefs all contribute to some extent . The amount of women not seeking or receiving prenatal care is increasing even in developing countries . There is a relationship between sociodemographic factors and poor utilization of the prenatal care program [28,34]. Financial support alone did not rule out the problem. Additional efforts like social support services and categorization of pregnant women were needed [11,25].
There is a great variation of prenatal care both between and within countries in terms of who sees mothers, when they are seen and what is done . Up to 70% of all pregnancies are followed and terminated by the traditional birth attendants in developing countries . As a matter of fact, there is no evidence that specialists are needed, or are cost effective in the prenatal care for every pregnant woman [19,24]. The frequency of prenatal visits is another debate: it has been proposed just in the 80’s that the number of visits could be reduced during pregnancy . In most developing countries even those women attending prenatal care do not receive all the benefits possible from these visits . Recently, it has been highlighted that there is lack of evidence for or against the effectiveness of care during pregnancy in reducing mortality or serious morbidity .
Poverty, malnutrition, inadequate sanitation and health services, low standards of education, high mortality rates and lack of statistics are common characteristics of developing countries . Maternal deaths may account for approximately one third of mortality for women of reproductive age in some countries . These factors may have a role for maternal mortality that can result from direct or indirect obstetric causes. Direct obstetric causes of maternal deaths are attributable to pregnancy itself, such as eclampsia or obstructed labor. Indirect maternal deaths are those resulting from, labor, puerperium or from a previously existing disease or disease that developed during pregnancy that was not due to direct obstetric causes, but was aggravated by physiologic effects of pregnancy .
Maternal mortality is defined as a ratio which is the number of maternal deaths during pregnancy, delivery, and the following 42-day period, excluding accidents or incidental causes, per 100,000 live births in a defined geographic area during one year. This term is mistaken for the maternal mortality rate, which is the number of maternal deaths per 100,000 women in the reproductive age group. Direct measurement of this rate or ratio is an impractical procedure in developing societies without on-going vital registration, except in specific research settings . The maternal mortality ratio is thus an imperfect indicator of reproductive health because it is hard to measure precisely. A global estimate of 515,000 maternal deaths in 1995, with a worldwide maternal mortality ratio of 397 per 100,000 live births was recently published . The differences, by region, were very great, with over half (273,000 maternal deaths) occurring in Africa (>1,000 per 100,000), compared with a total of only 2,000 maternal deaths in Europe (28 per 100,000) The country with the highest estimated number of maternal deaths was India (110,000), followed by Ethiopia (46,000), Nigeria (45,000), Indonesia (22,000), the Democratic Republic of the Congo (20,000), Bangladesh (20,000), the United Republic of Tanzania (13,000), Sudan (13,000), China (13,000), and Kenya (13,000). These ten countries account for 61% of all maternal deaths. On a risk-per-birth basis, the countries with the highest maternal mortality ratios were all in Africa; the top ten, in rank order, were Rwanda, Sierra Leone, Burundi, Ethiopia, Somalia, Chad, Sudan, Cote d’Ivoire, Equatorial Guinea, and Burkina Faso. In all, there were 22 countries in sub-Saharan Africa with maternal mortality ratios in excess of 1,000. Apart from Haiti, no country elsewhere in the world has a value in excess of 900 .
Universal underestimation of maternal mortality is another problem. These estimates have wide margins of error and should be seen as providing orders of magnitude only [29,31,44]. Use of the ‘Sisterhood Method’ may allow a more precise estimation of maternal mortality for the general population [8,26,30,32]. However some disadvantages of this method was notified .
Hospital based estimates are biased because only deaths of patients who survive until they reach the reference hospital are registered. In countries where women giving birth at home are in a high proportion, information on causes of death is obviously incomplete. The most accurate estimates for maternal mortality come from prospective population based surveys, which are extremely rare in developing countries .
Despite the worldwide desire to improve maternity care services and to contact pregnant women with these services, the role that pregnancy care has played in this dramatic decline in maternal mortality in developed countries is not clear . Improvement on the status of women, family planning programs, safe abortions, serious prenatal care, emergency obstetric services, training traditional birth attendants have also provided optimistic and pessimistic views of the potential of prenatal care to reduce maternal mortality .
Historically, obstetric care and delivery care have played a role in reducing mortality from hemorrhage and infection. Their role on anemia and hypertension in pregnancy is debatable . Lack of prenatal care is accepted as a risk factor in many studies [4,6,27,38], but this finding could be misinterpreted because of coexistence of unavailable primary health care facilities. However, especially in developing countries with high birth rates, prenatal care programs may play a role in informing the public about family planning and other health related issues allowing amelioration of health statistics. Decline in infant mortality after prenatal care attempts compared with no prenatal care is a good example for this concept .
Screening all pregnancies is an ideal prenatal care system. One may categorize pregnant women according to their needs during pregnancy. Low risk groups can choose their mode of surveillance freely in developed countries . This opportunity may not be available in developing countries because of the unfavorable outcomes. Unfortunately, risk-scoring systems are not satisfactory worldwide. The effectiveness of this kind of system must meet some criteria :
1-the whole population must be included in primary screening,
2-main causes of maternal mortality and morbidity must be included in the screening program,
3-when increased risk is detected appropriate referral must be taken,
4-referral services must be adequate,
5-at risk women must be able to reach the referral level and be motivated to do so,
6-all care providers must be trained and motivated,
7-this strategy must have proof of reducing mortality.
Known risk factors like very young age, lack of education and poverty are associated with low use of health services. Lack of a blood bank and anesthesia in a hospital is an example of inadequate service. Physical distance to the referral center is another problem . Good experiences on uncomplicated home deliveries and bad experiences on transferred women with poor outcomes influence the referral compliance of the pregnant women. Maternity waiting homes may be a solution for long distance or transport problems but they have to be assessed for their effectiveness .
Cesarean delivery, hospitalization and referral for delivery are not precise risk factors for maternal mortality. On the contrary, they prove that some severe complications were detected, and that they were transferred to a higher level of care. Delays in making these decisions, accomplishing patient’s transfer, and the performance of the cesarean may also contribute to the poor outcome. Sub optimal care was not limited to women who delivered at home. Complications, such as uterine rupture, also occurred within health care facilities at every level . Health services may also play other roles: past obstetric and medical histories can be erroneously obtained, follow-up during pregnancy by general practitioners or midwives can be ended by late diagnosis of malpresentation and underestimation of preeclampsia; prenatal record cards are best transferred by the pregnant women and not by the health workers .
Social, medical, obstetric factors and health workers play a multifactorial role in maternal mortality. The real cause of mortality may be masked by another complication leading to misclassification. WHO declared that two thirds of maternal mortality in developing countries arose from hemorrhage, hypertensive diseases, obstructed labor, infections, and unsafe abortion .
It can happen during any stage of pregnancy, labor or after birth. Mortality prevention depends on early treatment, prevention and blood replacement. All primary health services should be organized towards that goal . Risk assessment, prevention of anemia and early referral are the simplest methods to prevent it. Previous third stage hemorrhage, grand multiparity, multiple pregnancy and preeclampsia should be alarming factors.
Anemia is another factor contributing to mortality. The risk of death is greatly increased with severe anemia (Hb <7g/dL); but there is little evidence of increased risk associated with mild or moderate anemia. Cardiac failure and post hemorrhagic decompensation are the end results. Current programs of universal iron supplementation are unlikely to have much effect on severe anemia. There is an urgent need to reassess how to approach anemia control in pregnant women . Hemoglobinopathies and malaria are the other problems influencing the outcome of pregnancy and they must be assessed in specific geographical areas .
3 Hypertensive Disorders
Hypertensive disorders was the number one cause of maternal mortality in developed countries. While they remain at high numbers they may be obscured by hemorrhage, obstructed labor and sepsis in developing countries [10,32]). Early and late age periods at pregnancy, first pregnancy, genetic predisposition, underlying hypertension, multiple pregnancy, obesity, diabetes, excessive weight gain and proteinuria should alarm the medical team . Superimposed preeclampsia, eclampsia and HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome are the end points of these disorders. Abdominal pain, nausea and/or vomiting, headache, edema are nonspecific but alarming signs in HELLP syndrome. This syndrome following preeclampsia may lead to maternal mortality in one of 10 cases even in a tertiary center . Eclampsia, which may precede preeclampsia, is not preventable even in hospitals and may be fatal in one of four cases in rural areas .
Prediction of hypertensive disorder is based on face-to-face communication, on blood pressure measurement and on detection of generalized edema and proteinuria. Instrumentation and standard use consist a problem in developing countries . While prevention and early detection are controversial, management is universal: delivery. Timing of delivery may depend on the medical services facilities. Hospitalization may have some positive effects especially for hardworking women in developing countries. There is no evidence that strict bed rest improves the outcomes in this disorder . Some patients require antihypertensives and anticonvulsants but these approaches do not cure the disorder. Magnesium sulphate despite of its side effects is the first line therapy for prevention of the convulsions on eclampsia [21,36]. Expectant management of severe cases, which is preferred in some patients in developed countries, would end in a catastrophic manner especially in rural areas .
4 Obstructed Labor
In rural Africa, the lifetime risk of maternal mortality from childbirth may be as high as one in 15. Obstructed labor is one of the leading causes of this type of mortality in women with short stature that force to delay childbearing age and to revise the need of extra alimentation in teenage pregnancy . Previous delivery, which had required intervention (operative delivery), or experience of a stillbirth or neonatal death, should be alarming signs. Short maternal height, fundal height above standards, malpresentation and finally nulliparity had to be considered risk factors for obstructed labor . However, prevention and risk assessment of obstructed labor is not always feasible and it may become apparent just at the end of the second stage of the labor.
Health education, clean delivery, detection and treatment of genital infections, and recognition and treatment of preterm rupture of the membranes prevent puerperal infections that may cause maternal mortality. However, factors leading to an unclean delivery are probably more related to poverty. Increased number of vaginal examinations and septic interventions are common factors of untrained obstetrical assistance .
Depending on the prevalence and the adequate treatment of pregnant women and their partners, screening of sexually transmitted diseases (e.g. syphilis) could be beneficial in pregnancy. Gonorrhea may be worsened during pregnancy; endometritis and pelvic infection may precede puerperal infection. Other causes of infection like chlamydiatrachomatis and trichomonas vaginalis are of no value in maternal mortality. Only late stage HIV infection may be aggravated in pregnancy .
In developing countries other than obstetrical causes, infectious diseases contribute to the death of women during childbearing years . Higher prevalence of other diseases like hepatitis E and tuberculosis that aggravate pregnancy, may offer a potential for reducing maternal mortality if one pays attention to them during prenatal care.
Tetanus vaccination is recommended to all pregnant women on the first visit, who were not vaccinated earlier . Antibiotic use may be a benefit in preterm premature rupture of membranes. Screening for vaginitis and its treatment is subject of debate during pregnancy .
6 Unsafe Abortions
Abortions performed in an environment lacking medical standards, by untrained persons, or which are self-induced may play a hazardous role in maternal mortality. An estimated 20 million women (90% in developing countries) undergo an unsafe abortion each year, resulting in some 78,000 deaths and causing many millions of women to suffer chronic diseases and disabilities. Estimates of deaths attributable to unsafe abortions range from 0.3% to 83.8% of maternal deaths, with a global estimate of 13%. According to published data, the risks of mortality from unsafe abortion are greater for adolescents than for adults . Restrictive legislation does not prevent abortion, but may contribute to an increase in morbidity and mortality associated with pregnancy .
Up to half a million women die each year as a result of pregnancy; nearly all occurring in developing countries: pregnancy continues to be lethal! Low standards of health care for obstetric referrals, failure to recognize the severity of the problem at the community level, delays in starting the decision-making process to seek health care, lack of transport, and substandard primary health care were identified more than once as probable or possible contributing factors to maternal death commonly seen in developing countries .
In the vaste lecture of Carroli et al , the need of randomized controlled trials on the effectiveness of prenatal care on maternal mortality had been well documented. Main debates arise from methodology: small numbers, lack of statistical power and different orientations like quantity in spite of quality. The need is obvious: multicenter well planned studies, with clear objectives. The method to resolve the problem is to introduce practices with proven effectiveness.
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