Maternal Mortality in Developing Nations: Hemorrhage and Infection; Poverty and Inequality

Abstract

Background

It is often said that “statistics are people with the tears washed off;” this thesis was written with that in mind. Based on reviews of journals, ethnographies, and my own experiences in Mali, West Africa, I have created a thesis that blends a fictional first-person narrative with scientific discussion. In doing so, I hope to bring readers into the world of women who live in developing places where maternal death is a reality of life. This work shows readers how maternal deaths that are attributed to complications such as hemorrhage and infection are at their root caused by poverty and the inequality of women. Furthermore, it describes interventions that could be made to lower maternal mortality, many of which require relatively few resources.

Key interventions to reduce maternal mortality in developing places

Mariel Bryden

Mentor: Louis V. Kirchhoff, MD, MPH Departments of Internal Medicine and Epidemiology

1. Educate girls and women • Encourage girls to continue their formal schooling • Offer programs to educate women on health topics • Teach women that prenatal consultations save lives • Place more value on girls and women and their work • Allow women to make their own decisions about their health care and pregnancy – end spousal authorization

2. Alleviate poverty • Provide viable economic opportunities for men and women • Invest in education and health care

3. Give health workers better tools to do their jobs • Enhance and expand formal training of midwives and nurses, and provide continuing medical education • Bring matrone training up to the level of international standards for skilled birth attendants • Improve health care facilities and equipment, and provide for ways to properly sterilize tools • Provide practitioners of traditional medicine with some biomedical training

4. Enhance availability of contraceptives • Make them obtainable through government health centers at affordable prices • Educate men and women on risks of grand multiparity and advantages of smaller families

5. Create systems of reliable emergency transportation • Organize villages to create plans and means to transport people who need emergency medical attention that cannot be addressed locally • Put pressure on local and national government to address this issue

Scenario 1 in Figure 1 above summarizes the story of Sayun Dembélé,* a 17-year-old girl who had an abortion while she was away at high school in the capital, Bamako. Sayun slept with an older man who gave her money for schoolbooks and clothing, and because she did not know how to obtain or use contraceptives, she became pregnant. She traveled back home after she became sick following an unsafe abortion that punctured her uterus. The damage to her uterus caused hemorrhage which led to her death. This scenario could have been prevented if contraceptives were readily available and affordable through government-run health centers. She would not have slept with the older man at all, though, if she had enough money to buy her own books and respected herself as a woman more.

Scenario 2 is the story of Mariam Kamarra,* a 14-year-old girl who had recently married an older man because her family needed the bride price they earned from this arranged marriage. Mariam’s pelvis was too narrow for her to deliver vaginally both because of her young age and stunted growth due to poor nutrition. Because the decision to transport her to a hospital was made too late and the transportation (a donkey cart) was too slow, she died en route. If Mariam would have been enrolled in school, she would not have married at such a young age. Schooling of girls should be encouraged in part for this reason. Alternatively, if Mariam would have gone to the health center for prenatal consultations, a skilled health care provider would have told her that she would need to go to a hospital for the delivery.

In Scenario 3, 43-year-old Awa Keita* was pregnant for the ninth time. Because she did not attend prenatal consultations, Awa was not aware of her pregnancy-induced hypertension. If she would have attended these appointments, the health care provider would have categorized hers as a high-risk birth due to her older age and grand-multiparity. She would have been sent to give birth at a hospital where eclampsia could have been prevented or treated. Additionally, if contraceptives were available to Awa she might have never become pregnant in the first place.

Scenario 4 is the story of the protagonist Oumou Diarra.* In Oumou’s first pregnancy, she was sick with malaria because she did not know how to prevent infection with mosquito nets and chemoprophylaxis. Oumou miscarried due to her infection, but she was never aware because she did not attend prenatal consultations. After the traumatic delivery of the miscarried baby, Oumou contracted a life-threatening infection due to the midwife’s use of non-sterile instruments to artificially rupture the amniotic sac.

The paper ends with the story of Oumou’s successful birth after her sister-in-law, Kany Keita,* the new midwife, teaches the women of the village about what went wrong in Awa, Mariam, Sayun, and Oumou’s scenarios and how they can prevent these things from happening to them and their families.

Stories of Maternal Death in Mali

Childbirth is naturally a high-risk part of women’s lives. However, in some parts of the world, the chances of dying in childbirth are much higher than others: women in developing countries face a staggering one in 16 chance of death for each pregnancy (Beyond the Numbers).

The UN’s Millennium Development Goals are targets created to address the world’s biggest problems, including maternal mortality. The fifth goal mandates a reduction in maternal mortality by 75% between the years of 1990 and 2015 (WHO Millennium Development Goals). To accomplish this goal, progress must be accelerated greatly.

The most common direct causes of maternal mortality in developing places worldwide include hemorrhage, infection/sepsis, hypertensive disorders, obstructed labor, and complications of abortion (WHO Causes of Maternal Death). Indirect causes of mortality and morbidity abound, with poor nutrition, malaria, HIV/AIDS, and anemia contributing most. In Africa, hemorrhage and infection are the biggest killers (see Figure 2). Complications seen in developing countries that so frequently lead to death are rarely fatal in settings with higher-quality healthcare. Modest healthcare facilities and providers with relatively little training can make an enormous difference in maternal mortality (Khan et al.).

Selected Bibliography WHO. Beyond the Numbers: Reviewing maternal deaths and complications to make pregnancy safer .

World Health Organization; 2004.

WHO Millennium Development Goals [Internet]. Available from: http://www.who.int/making_pregnancy_safer/mdg/en/

WHO. Causes of Maternal Death [Internet]. Available from: http://www.who.int/reproductive-health/MNBH/causes_maternaldeath_flyer.pdf

Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. The Lancet. 367(9516):1066-1074.

WHO. Maternal Mortality in 2005 [Internet]. Available from: http://www.who.int/reproductive-health/publications/maternal_mortality_2005/mme_2005.pdf

Filippi V, Ronsmans C, Campbell OM. Maternal health in poor countries: the broader context and a call for action. The Lancet. 2006 Oct 28;368(9546):1535-1541.

Huge poor-rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries. Bulletin of the World Health Organization. 2007 Oct;85(10):745-754.

Einarsdottir J. Tired of Weeping: Mother Love, Child Death, and Poverty in Guinea-Bissau. University of Wisconsin Press; 2004.

Center for Reproductive Rights. Claiming our Rights: Surviving Pregnancy and Childbirth in Mali. [Internet] Available from: http://www.reproductiverights.org/pub_bo_mali.html#report

Malawi Safe Motherhood Programme. Making Motherhood Safe for Malawian Women. 1995.

Fighting for life in birth [Internet]. BBC. 2001 May 11; Available from: http://news.bbc.co.uk/2/hi/africa/1325293.stm

Allen DR. Managing Motherhood, Managing Risk. University of Michigan Press; 2002.

Holloway K. Monique and the Mango Rains: Two Years with a Midwife in Mali. Waveland Press, Inc; 2007.

Dettwyler KA. Dancing Skeletons: Life and Death in West Africa. Waveland Press, Inc; 1994.

Burns AA, Lovich R, Maxwell J, Shapiro K. Where Women Have No Doctor: A health guide for women [updated edition]. Hesperian Foundation; 1997.

Dujardin B, et al. Oxytocics in developing countries. International Journal of Gynecology & Obstetrics. Sept 1995;50(3): 243-251.

Pre-eclampsia Eclampsia Older women giving birth

Girls marry and get pregnant young

Grand multiparity (7+ pregnancies)

Pregnancy-induced hypertension

Girls lack education

No use of contraceptives

Unwanted pregnancy

Unsafe abortion Organ damage Hemorrhage

No money/ availability

Not enough food available/ girls fed less than boys

Poor nutrition

Smaller pelvis

Obstructed labor

Ruptured uterus

MATERNAL MORTALITY

Girls lack education

No use of precautions against malaria

Malaria infection MISCARRIAGE

POVERTY and

INEQUALITY OF WOMEN

Figure 1) Some roads to maternal mortality in developing places. Lightning bolts show key points for potential intervention.

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2

3 4

Figure 2) Top causes of maternal mortality in Africa from 1997-2002. Source: UNICEF

* Please note that these are all fictional names and stories, though they are based on reality. May 2008