MATERNAL HEALTH

Learning objectives:
• Describe the safe motherhood initiative and services included
under safe motherhood

• Understand important causes of maternal mortality

and morbidity

• Describe maternal health services

• Understand methods of maternal mortality measures

and their challenges

1. Introduction

Motherhood should be a time of expectation and joy for a woman, her

family, and her community. For women in developing countries, however,
the reality of motherhood is often grim. For those women, motherhood
is often marred by unforeseen complications of pregnancy and childbirth.
Some die in the prime period of their lives and in great distress: from

hemorrhage, convulsions, obstructed labor, or severe infection after

delivery or unsafe abortion.

Worldwide, it is estimated that 529,000 women die yearly from

complications of pregnancy and childbirth— about one woman every
minute. Some 99 percent of these deaths occur in developing countries,
where a woman's lifetime risk of dying from pregnancy-related
complications is 45 times higher than that of her counterparts in
developed countries. The risk of dying from pregnancy-related
complications is highest in sub- Saharan Africa and in South-Central Asia,
where in some countries the maternal mortality ratios are more than
1,000 deaths per 100,000 live births.

Sixty to eighty percent of maternal deaths are due to obstetric

hemorrhage, obstructed labor, obstetric sepsis, hypertensive disorders of
pregnancy, and complications of unsafe abortion. These direct
complications are unpredictable and most occur within hours or days after
delivery.

2. The Safe Motherhood Initiative

In 1987 the World Bank, in collaboration with WHO and UNFPA, sponsored
a conference on safe motherhood in Nairobi, Kenya to help raise global
awareness about the impact of maternal mortality and morbidity. The
conference launched the Safe Motherhood Initiative (SMI), which issued
an international call to action to reduce maternal mortality and morbidity
by one half by the year 2000. It also led to the formation of an Inter-
Agency Group (IAG) for Safe Motherhood, which has since been joined by
UNICEF, UNDP, IPPF, and the Population Council.

The SMI's target has subsequently been adopted by most developing

countries. Under the Safe Motherhood Initiative, countries have
developed programs to reduce maternal mortality and morbidity. The
strategies adopted to make motherhood safe vary among countries and
include:

• Providing family planning services.

• Providing post abortion care.
• Promoting antenatal care.
• Ensuring skilled assistance during childbirth

• Improving essential obstetric care.

• Addressing the reproductive health needs of adolescents.

As we can see from the following table, risk of death from pregnancy is
very high in developing countries, while being very low in the developed
world. This shows that the difference is due to the quality of care provided
to mothers.
1.1. Essential Services for Safe Motherhood

Safe motherhood can be achieved by providing high- quality maternal

health services to all women. These services for safe motherhood should
be readily available through a network of linked community health care
providers, clinics and hospitals. These services could be provided at
different levels including home and health institutions.

Essential Services include:

1. Community education on safe motherhood

2. Prenatal care and counseling, including the promotion of

maternal nutrition

3. Skilled assistance during childbirth

4. Care for obstetric complications, including emergencies

5. Postpartum care

6. Post-abortion care and, where abortion is not against the law,

safe services for the termination of pregnancy

7. Family planning counseling, information and services

8. Reproductive health education and services for adolescents

1.2. Causes of Maternal Mortality and Morbidity

1.2.1. Definitions

▪ The Tenth Revision of the International Classification of Diseases

(ICD-10) defines a maternal death as the death of a woman while
pregnant or within 42 days of termination of pregnancy,
irrespective of the duration and site of the pregnancy, from any
cause related to or aggravated by the pregnancy or its
management, but not from accidental or incidental causes.
 ▪ Maternal morbidity: Any deviation, subjective or objective, from
a state of physiological or psychological well being of women.

▪ Women’s lifetime risk of Death: Is the risk of an individual

woman dying from pregnancy or childbirth during her lifetime. Of
the 171 countries and territories, Niger has the highest lifetime
risk of maternal death (1 in 7 women die for reasons associated
with pregnancy and child birth)

Table 1: Women's Lifetime Risk of Death from Pregnancy, 2000

Information adapted from AbouZahr C, Wardlaw, T. Maternal Mortality in 2000: Estimates Developed by
WHO, UNICEF and UNFPA. Geneva: WHO; 2000

More than one woman dies every minute from

complications of pregnancy and childbirth.

Maternal care is in the lowest level of use particularly in the developing

countries. Preventing maternal death is almost equivalent with upgrading
the socioeconomic status of the country in particular. No body knows the
exact number of maternal deaths each year due to poor epidemiological
studies and poor recording of health care institution.

Women’s lifetime risk of death is 40 times higher in developing countries

compared to developed countries. In general, women lifetime risk of
death in developing countries is 1 in 48 as opposed to 1:1800 in developed
countries. Maternal mortality ratio is by far the greatest disparity between
developed and developing countries.

More than seventy percent of maternal deaths are due to hemorrhage,

unsafe abortion, hypertensive diseases of pregnancy, infection and
obstructed labor, which are preventable. Out of this, more than 60% of
maternal deaths occur following delivery, of which half occur in the first
day after delivery.

Causes of maternal Mortality

Direct obstetric deaths are those that result from obstetric complications
of the pregnancy state from interventions, omissions, incorrect treatment
or from chain of events.

Examples: Abortion, Ectopic pregnancy, pre-eclampsia, Eclampsia,

Obstructed labor, infection, etc.

Seventy percent of maternal deaths are usually preventable. The

commonest causes of maternal deaths include:
A. Hemorrhage: Includes antepartum, postpartum, abortion, and
ectopic pregnancy.

B. Unsafe Abortion: It is claimed as the commonest cause of

maternal death in our country accounting for 20 –40% of
deaths.

C. Hypertensive disorders of pregnancy: This includes pre-

eclampsia, eclampsia, etc. Preclampsia and eclampsia account
for 10- 12% of maternal deaths.

D. Obstructed Labor and uterine rupture: The prevalence of

obstructed labor is said to be 47
% in Ethiopia. It accounts for 9% of the total maternal death.
 E. Infection: The introduction and multiplication of microbial
agents in the pelvic organs and other systems having an effect
on the health of the mother and newborn. It includes infection
of the uterus, tubes, urinary system and fetal infection. It
accounts for 10% of maternal deaths.

Indirect Obstetric Death

Deaths resulting from previous existing diseases or diseases that

developed during pregnancy, which are aggravated by the physiologic
effects of pregnancy. This includes:-

A. Anemia: This is the commonest indirect cause of maternal death

in our country, since malaria is endemic and iron supplementation
is low.
B. Other indirect causes include, heart disease, diabetes mellitus,
HIV/AIDS, TB, Malnutrition, etc. The indirect obstetric death:

Incidental/Coincidental/ causes of maternal Death:

Deaths that are neither due to direct nor indirect obstetric causes: E.g.
Car accident, fire burn, bullet injury

1.2.2. Medical Causes of Maternal Death

Direct Causes Indirect causes

Hemorrhage HIV
Hypertensive diseases Malaria
Infection and sepsis Anemia
Obstructed labor Cardiovascular diseases
Abortion Others
Others
– Embolism
– Anesthesia
1.2.3. Maternal Mortality in Context: The Three D’s (Delays)

• Delays can kill mothers and newborns. There are three phases
during which delays can contribute to the death of pregnant and
postpartum women and their newborns.

1. Delay in deciding to seek care

o Failure to recognize signs of complications

o Failure to perceive severity of illness

o Cost consideration

o Previous negative experience with the health system

o Transportation

2. Delay in reaching care

o Lengthy distance to a facility

o Conditions of roads

o Lack of available transportation

3. Delay in receiving appropriate care

o Uncaring attitudes of providers

o Shortages of supplies and basic equipment

o Non-availability of health personnel

o Poor skills of health providers

Life threatening delays can happen at home, on the way to care, or at the
place of care. Therefore, plans and actions that can be implemented at
each of these points are mandatory.

o Birth preparedness and complication readiness to reduce delays

o Women-friendly care to enhance acceptability

2. 2.5. Risk factors for Maternal Health

Socio-cultural factors: Like early marriage, early childbirth, harmful

traditional practices including female genital mutilation, etc.

Economy: Socio economic status affects the women’s status by

affecting their decision making roles in the community, educational
status, health coverage, level of sexual abuse, etc.

Inadequate Health Service Coverage: Most mothers do not get care

during pregnancy and most deliveries are unattended. This is due to
lack of transportation, distance from health facilities, small number of
health facilities, etc.

Psychological factors: For instance, after sexual abuse women are at

great risk of depression.

Health and nutrition services: The health status of women who are
not getting adequate amount of nutrients and proper reproductive
health services could be affected.

Interaction with providers: Some health care providers are,

unsympathetic and uncaring as they do not respect women's cultural
preferences. E.g. privacy, birth position, or treatment by women
providers.