Reproductive health 3.pptx lecture one intoduction

Maternal Health
Dr. Abdi Kynan, MD.

Introduction
 Motherhood is ideally a joyful experience, but for many women in
developing countries it is overshadowed by serious and often fatal
complications during pregnancy and childbirth.
 Every year, about 529,000 women mostly in developing nations die from
issues such as hemorrhage, obstructed labor, infection, hypertension, or
unsafe abortion. This means a woman dies approximately every minute.
 Women in these regions face a risk of pregnancy-related death that is 45
times higher than in developed countries, with the highest mortality rates
found in sub-Saharan Africa and South-Central Asia. Most of these
deaths result from sudden, unpredictable complications occurring shortly
after delivery.

The safe motherhood initiative
 The Safe Motherhood Initiative (SMI) was launched in 1987 during a World
Bank, WHO, and UNFPA conference in Nairobi to raise global awareness
about maternal mortality. The initiative called for reducing maternal deaths
and illness by half by the year 2000 and led to the creation of the Inter-
Agency Group for Safe Motherhood, later joined by several major
international organizations.
 Most developing countries adopted the SMI’s target and created programs to
improve maternal health. These strategies include family planning, post-
abortion care, antenatal care, skilled birth attendance, essential obstetric
services, and addressing adolescent reproductive health needs. The initiative
highlights that high pregnancy-related death rates in developing countries are
primarily due to poor-quality maternal care compared to developed nations.

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

Essential Obstetric Care
Essential obstetric care is crucial for reducing maternal deaths and
comes in two levels: basic essential obstetric care (BEOC) provided at
health centers, which includes antibiotics, oxytocic drugs, sedatives for
eclampsia, manual placenta removal, removal of retained products, and
assisted vaginal delivery; and comprehensive essential obstetric care
(CEOC) at district hospitals, which adds surgery, anesthesia, and blood
transfusion. WHO recommends at least four BEOC facilities and one
CEOC facility per 500,000 people.

After ten years of implementing the Safe Motherhood Initiative, global
experience showed that maternal deaths can largely be prevented by
recognizing that every pregnancy carries risk, ensuring access to family
planning, improving antenatal and postpartum care, expanding
midwifery and skilled personnel, providing essential obstetric and post-
abortion care, strengthening referral systems, and reforming laws to
support women’s health.

Key lessons learned include the importance of strong political
commitment, involvement of leaders and communities, training
diverse health workers, effective communication between health
service levels, and educating communities about obstetric
complications. The review also noted past strategic mistakes, such as
relying too heavily on risk-based antenatal care and expecting
traditional birth attendants to manage delivery complications.

Causes of maternal mortality and morbidity
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.

Definitions
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)

Women's Lifetime Risk of Death from Pregnancy, 2000
Information
adapted from
AbouZahr
Wardlaw. Maternal
Mortality in 2000:
Estimates
Developed by
WHO, UNICEF
and UNFPA.
Geneva: WHO;
2000

Epidemiology
In many developing countries, including Ethiopia, complications of
pregnancy and childbirth are the leading causes of death among
women of reproductive age.
More than one-woman dies every minute from such causes. In
2005 more than 636,000 women worldwide. From that, 99% was
accounted by developing countries. Of those, around 270,000
women died in Africa.

Causes of maternal Mortality
Direct obstetric deaths are deaths that happen because of pregnancy
complications or problems caused by medical care during pregnancy, labor, or
after delivery.
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. Preeclampsia 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.

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

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
 Failure to recognize signs of complications
 Failure to perceive severity of illness
 Cost consideration
 Previous negative experience with the health system
 Transportation

2. Delay in reaching care
 Lengthy distance to a facility
 Conditions of roads
 Lack of available transportation
3. Delay in receiving appropriate care
 Uncaring attitudes of providers
 Shortages of supplies and basic equipment
 Non-availability of health personnel
 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.
 Birth preparedness and complication readiness to reduce
delays (planning early for a safe delivery and knowing what
to do if problems happen, so that there are no delays in
getting care).
 Women-friendly care to enhance acceptability (providing
respectful, comfortable, and supportive services so women
feel safe and happy to use healthcare.)

Causes of Maternal Morbidity
Maternal morbidity is difficult to measure due to variation in the
definition and criteria to diagnose. The risk factors for maternal
morbidity include prolonged labor, hemorrhage, infection,
preeclampsia, etc.
The commonest long term complication of pregnancy and child birth
include:
A. Infection: There is high risk of infection of the genital organs
(cervix, uterus, tubes, ovaries and peritoneum) after prolonged labor,
unclean delivery settings, retained parts of conception after unsafe
abortion and delivery.

B. Fistula: are holes in the birth canal that allow leakage from the
urethra, bladder or rectum into the vagina.
C. Incontinence: is leakage of urine upon straining or standing.
D. Infertility: Unable to be pregnant for a year despite unprotected
sexual intercourse.
E. Uterine prolaps: the falling or sliding of the uterus from its
normal position into the vaginal canal. Commonest predisposing
factors include prolonged labor, heavy exercise, multiple
childbirths, etc.

F. Nerve Damage: As a result of prolonged labor, there may be
compression or damage of the nerves in the pelvis (Sciatic nerve).
G. Psychosocial problems: maternal blues aggravated by other
conditions.
H. Others, Include, pain during intercourse, anemia, etc.

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.

Risk factors for Maternal health
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.
Gender Discrimination: E.g. lack of women empowerment,
giving more attention to a male child.

Maternal health services
Antenatal Care (ANC)
Antenatal care is the care given to pregnant women to help ensure a
safe pregnancy and a healthy baby. Although pregnancy is a
normal process, it carries risks that can be reduced through proper
ANC.
Global ANC Coverage
 Worldwide, about 70% of women receive at least one ANC visit.
 Industrialized countries: 98% coverage.
 Developing countries: about 68% (lowest in South Asia at 54%).
 Sub-Saharan Africa: about 68%, but Ethiopia is much lower at
28%.

Purpose of ANC
 Detect early signs of problems or diseases.
 Provide timely interventions.
 Improve baby’s health, growth, and survival.
 Promote healthy behavior and birth preparedness.
 Serve as a platform for other health services (malaria prevention,
HIV care).
Criticisms of Traditional ANC
 Often ritualistic, lacking clear goals.
 Focus on number of visits instead of useful actions.
 Limited communication and counseling.
 Poor emphasis on birth preparedness.
 Risk assessment based on old methods that are not effective

Improved ANC Model
 WHO recommends 4 goal-oriented visits, which are proven as
effective as many-visit models.
 Care provided by midwives or general practitioners is as effective
as specialist-led care.
Goal-Oriented Interventions Include:
 Detecting and treating anemia
 Preventing obstructed labor (e.g., external cephalic version)
 Tetanus immunization
 Promoting clean and safe delivery

Reproductive health 3.pptx lecture one intoduction

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