MAY/JUNE 2004

FORUM

Where motherhood might mean death: Obstetrics in the developing world

The Roman poet Ovid, marveling at the advances made during the Age of Augustus, wrote, “Let others praise ancient times, I am glad I was born in these.” Two thousand years later, in medicine as in other facets of our lives, we may echo the sentiments of the poet, recognizing what the modern age affords us, and imagining what might be possible in the future.

In the developing world, the very first thing we do as humans—the act of being born—still carries with it significant risk. In countries like Niger, Chad, Ethiopia, and a host of other underdeveloped nations, maternity is closely intertwined with the prospect of untimely death. It is estimated that annually, more than 500,000 women globally die as a result of pregnancy or childbirth. That 99 percent of these deaths occur in the developing world calls into question what Ovid referred to as “ancient times.” Arguably the time of the ancients is now for many women who lack access to the obstetric care to ensure healthy deliveries. In this issue of HMI World, we look at the state of obstetric care in the developing world, and, with hope that this crisis will receive the attention it so sorely deserves, explore opportunities to improve obstetric care and preserve one of the world ’s most important natural resources: motherhood.

Dr. Lori Berkowitz of Massachusetts General Hospital helped to perform pelvic reconstructive surgery on fistula sufferers in Niger.

The burden of motherhood
It is crushing enough to cite a figure like half a million to give some indication of the heavy toll of the crisis of maternal mortality. Pointing out that 99 percent of maternal deaths occur in the developing world drives home the ugly truth that maternal mortality is the health care issue with the largest disparity between developed and developing countries. But these statistics only hint at the real impact of the death of a mother, at the enormous human and economic cost to her nation, her community, and family. For every woman who dies due to complications resulting from pregnancy, 30 to 50 survive but must cope with infection, disease, injury, and in the sad case of fistula, stigmatization (see sidebar). The death of a mother often results in a motherless child, one whose chances of growth and survival diminish significantly without a mother to provide nurturing and support. Of course, some of these children don’t make it either. The same factors that cause maternal mortality and morbidity contribute to an estimated 8 million stillbirths and newborn deaths every year.

Dr. Raymond Powrie, associate professor of medicine and obstetrics at Brown University, said that maternal death is defined as any death that occurs during pregnancy or within 42 days of the end of pregnancy. “The causes of maternal mortality can be divided between direct causes, such as sepsis or pre-eclampsia, and indirect causes, by which we mean conditions, such as rheumatic heart disease, that are independent of the pregnancy, but are worsened by pregnancy or its complications,” said Powrie. Severe bleeding, infection, and unsafe abortion rank at the top of the list of leading causes, followed by eclampsia and obstructed labor. Indirect causes are estimated to represent about a fifth of maternal mortality.

Understanding the problem: the parts versus the whole
Health care leaders have worked to better understand the dramatic reduction in maternal mortality rate that occurred in the U.S. and other western industrialized countries a century ago, and find ways to apply those lessons to the developing world. What has been found is that improvements in health care delivery must follow advancements in quality of life.

Dr. Benjamin Sachs, head of obstetrics at Beth Israel Deaconess Medical Center, said that when attempting to formulate a solution to the dire state of maternal care in the developing world, it is important to understand that the decline in maternal mortality in western industrialized countries like the U.S. and the UK began to occur long before what we know today as modern obstetrics had come of age. “Before the introduction of antibiotics, blood banking, or even penicillin, a host other factors related to overall quality of living contributed to the increased safety of obstetrics,” he said, “including better sanitation and nutrition, an acceptance of hand washing techniques, reasonably aseptic conditions, the spacing of pregnancies, and the availability of some even primitive family planning. ”

Dr. Benjamin Sachs: “Education for birth attendants is an urgent issue, and one of the keys to reducing maternal mortality in the developing world.”

One of the challenges of improving maternal outcomes in underdeveloped countries, however, is that raising the standard of maternal care is unlikely to happen in countries that are not investing in their overall infrastructure—in sanitation and sewage systems, in infection-free health care environments, and in education to help disseminate information about reproductive health and thereby prevent many problems before they arise. “When you look at ways to fight against this problem, you’re attempting to apply modern medicine in order to counteract the fact that when a woman delivers a baby in a hospital, she often goes home to a situation where sanitation is so poor that the infant develops a gastrointestinal infection and dies,” said Sachs.

A lack of skill when it’s time to deliver
One issue that has become all too familiar in the developing world is the shortage of skilled health care professionals—a serious problem in the field of obstetrics. Just over half of the births in the developing world are professionally attended. This means that every year an estimated 60 million women in developing countries give birth cared for by only a family member, a traditional birth attendant (or doula), or no one at all.

While some in the medical community argue that non-physicians are a barely tapped resource of maternity care, others point out that midwives can sometimes do more harm than good. Making the most of this resource requires a combination of education and tools. “The vast majority are relatively not very skilled and don’t have access to training. There is a huge problem in places like sub-Saharan Africa where midwives often are not able to wash their hands with clean water and use sterile gloves while examining a patient internally,” said Sachs. But even a highly skilled midwife can be limited by a lack of resources. “If she doesn’t have the basic tools, there is a limit to what she can do in an environment where she can’t tie off an umbilical cord safely without causing a tetanus infection or some other complication that arises in that situation.”

These basic technologies include sterilized gloves, antibiotics to treat infections, such as those that occur following a miscarriage, and medications such as oxytocin (pitocin®) and misorpostol to deal with post-partum hemorrhage—the availability of which should be within reach. “We’re talking about pennies, really, to enable these women to better and more safely do their jobs,” said Sachs. “Education for birth attendants is an urgent issue, and one of the keys to reducing maternal mortality in the developing world.”

Dr. Raymond Powrie: “While some procedures are beyond the reach of non-physician birth attendants, others are highly successful if the delivery environment and basic instruments are clean.”

When childbirth becomes an emergency
Although routine prenatal care can prevent some of the problems associated with maternal death, said Dr. Mark Hauswald, associate professor of emergency medicine at the University of New Mexico, in reality most maternal problems are unpredictable until labor ensues. “You can assess risk based on a number of factors, but even with a decent health infrastructure, most bad outcomes come with very little warning prior to labor. This makes them emergencies,” he said.

Acute hemorrhaging (about a quarter) and infection (about 15 percent) are two of the leading causes of maternal death globally. Hauswald explains that controlling hemorrhages may require venous access, the ability to transfuse blood safely, and the equipment to stop bleeding. Post-miscarriage infections require the use of antibiotics which are often unavailable.

Powrie has spoken around the world to health care professionals about approaches to treating pregnant women who are ill, without compromising the safety of mother or child, and without allowing conditions to worsen. These approaches can reduce the risk of complications, but what about when it’s time for labor? Many complications, said Powrie, can be addressed if the birth attendant has access to parenteral antibiotics, oxytocin and/or misoprostol, and anticonvulsants. And a number of procedures are essential to high-quality obstetric care: manual removal of the placenta, removal of retained products of conception, cesarean delivery, assisted vaginal delivery (using forceps or vacuum extraction), and blood transfusion. “The prevention and treatment of anemia also remains one of the biggest obstetrical challenges in the developing world,” said Powrie. “While some procedures are beyond the reach of non-physician birth attendants, others are highly successful if the delivery environment and basic instruments are clean.”

Hauswald emphasized that it is possible to train midwives to perform some simple procedures that require basic instruments and technology, but the risk is still extremely high. “Although these are not highly sophisticated procedures, it’s very easy to perforate a uterus and cause more damage,” he said. “And while there are actions they can take to stop bleeding, something like scraping out a uterus is demanding.”

In some cases, the development of emergency obstetrics skills—not only of non-physician birth attendants, but doctors as well—is hindered by cultural or legal constraints. “Uterine curettage is one of our best tools for treating acute hemorrhage. In places where abortion is legal, doctors can gain a lot of experience with this procedure,” said Hauswald. “But if abortion is illegal, there may not be enough opportunities for doctors to train in how to perform this life-saving procedure.”

Just because abortion is illegal in many countries does not mean that it does not make up a significant portion of the underground “medical” community. Unsafe abortion is the cause of an estimated 12-15 percent of maternal mortality worldwide. Hauswald pointed out that abortions were a major cause of maternal mortality in the U.S. prior to legalization, but complications from them are now rare. Both Hauswald and Sachs can attest to the prevalence of “backstreet” abortions in South America and Asia. “In the Philippines, I have seen a dramatic rise in the number of unwanted pregnancies and backstreet abortions, and an increase in the number of children having children,” said Sachs. “I cannot emphasize enough the impact that basic family planning could have on the maternal mortality rate in the developing world. This is one of the lessons we have extrapolated from the dramatic decrease in maternal death here in the U.S. and in other developed nations.”

A human rights issue—and a plan for improvement
In March, the World Health Organization and UNICEF, through a joint press release, trumpeted a significant increase in the number of pregnant women in the developing world that are receiving antenatal care. The greatest progress has been in Asia, which has seen an estimated increase of 31 percent, while Bangladesh, Ethiopia, Morocco, Nepal, and Yemen have made only modest gains. Carol Bellamy, UNICEF’s executive director, said, “The advantages of receiving regular antenatal care cannot be stressed enough. These findings have enormous significance for maternal health and child survival.”

Yet even this mildly celebratory press release is marked with restraint, pointing out that this increase in antenatal care signals that “an untapped opportunity exists to reach poor women with a whole package of life-saving health services.” The tempered optimism is appropriate, particularly because in much of the developing world, maternal health remains, first and foremost, a human rights issue. For women, these rights include the availability or quality services and information during and after pregnancy and childbirth, as well as the right to make their own decisions about their health freely. “Without changing the role of women in society and the value placed on women’s lives, I’m not sure that resources are going to be made available nor is emphasis going to be placed on reproductive health,” said Sachs.

Hauswald believes that improving maternal care and general health care must be done simultaneously. “Acute care requires similar skills and equipment regardless of the problem. There is a lot of overlap between the care given to pregnant women and that given to other people,” he said. “A minimal infrastructure that can deal with maternal mortality issues can also have an impact on other emergencies. For example, a hospital that can give safe blood to a woman with severe post-partum hemorrhaging can also transfuse a man after a traffic accident.”

Ruminating about advances in medicine, Ovid wrote, “Time is generally the best doctor.” It may be true that nothing will raise the stature of women in the developing world as much as the passage of time, with new generations embracing new attitudes about the value of women’s health. But the problem of maternal mortality, which is essentially an issue of safety, requires urgency, not simply because of the staggering number of preventable deaths and disabilities, but because this issue, if unremedied, will have a disastrous long-term impact on countries where the population is already dwindling due to other health care problems. Education, the simple tools of medicine, and action—these are certainly elements of the prescription for reducing maternal mortality in the developing world. The question now for international health care leaders, governments, and activists is how to bring these elements into the areas of greatest need.

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