CHAPTER THREE
MATERNAL HEALTH
LECTURE 3
SESSION THREE
ADMAS UNIVERSITY GAROWE
PUNTLAND SOMALIA
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.
•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.
•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.
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.
❖ 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.
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.
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 of two types basic
essential obstetric care and comprehensive
essential obstetric care. Ensuring access to essential
obstetric care is important in reducing maternal
deaths.
❑Basic essential obstetric care (also called basic
emergency obstetric care) at the health center
level should include at least:
- Parenteral antibiotics
- Parenteral oxytocic drugs
- Parenteral sedatives for eclampsia
- Manual removal of placenta
- Removal of retained products
- Assisted vaginal delivery
❑Comprehensive essential obstetric services at
district hospital (first referral level) should
include all of the above, plus:
– Obstetric Surgery
– Anesthesia
– Blood transfusion
❑ Global experience showed maternal mortality and
morbidity could be prevented with the existing
knowledge and technology by:
• Recognizing that every pregnancy faces risk
• Increasing access to family planning services
• Improving quality of ANC and postpartum care Ensuring access
to essential obstetric care (including post-abortion care)
• Expanding access to midwifery care
• Training and deploying appropriate skilled health
personnel
• Reforming laws to expand women’s access to
health services and to promote their health
interests
Causes of Maternal Mortality
and Morbidity
Definitions
• 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.
•Maternal mortality and morbidity can be reduced
or avoided by providing and expanding resources and
services that are principally targeted in achieving
maternal health and safe motherhood.
More than one woman dies every minute
from complications of pregnancy and
childbirth.
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.
- Hemorrhage accounts for 21% of maternal
deaths in Somalia.
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 Somalia. 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.
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.
Medical Causes of Maternal Death
Direct Causes
•Hemorrhage
•Hypertensive diseases
•Infection and sepsis
•Obstructed labor
•Abortion
•Others
• – Embolism
•– Anesthesia
Indirect causes
•HIV
•Malaria
•Anemia
•Cardiovascular diseases and Others
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.
o Birth preparedness and complication readiness to
reduce delays
o Women-friendly care to enhance acceptability
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, when delivery
takes place in unclean 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. They present with continuous leakage of urine
or feces or both. The commonest cause in our country is
obstructed labor as opposed to surgery and cancer in the
developed world.
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 prolapse: 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.
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.
The Risk Approach in Pregnancy
•The risk approach is a managerial tool for health
services to identify people at risk as early as possible
and intervene in order to reduce the risk.
•It is the screening and classification of the risk level of
pregnancies based on maternal characteristics.
A. Focused antenatal care (New ANC approach)
•Traditional antenatal care uses risk approach to
classify which women are more likely to develop
complication and assumes that more visits means
better outcome for the mother and the baby.
The main goals of the focused antenatal care are:
•Goals of Focused ANC: The new approach to ANC
emphasizes the quality of care rather than the quantity. For
normal pregnancies, WHO recommends only four
antenatal visits. The major goal of focused antenatal care is
to help women maintain normal pregnancies through:
• Identification of pre-existing health conditions
• Early detection of complications arising during the
pregnancy
• Health promotion and disease prevention
• Birth preparedness and complication readiness planning.
All pregnant women should receive the following preventive
interventions:
• Immunization against tetanus
• Iron and folate supplementation.
In areas of high prevalence women should also receive:
• Presumptive treatment of hookworm
• Voluntary counseling and testing for HIV
• Protection against malaria through intermittent
preventive treatment and insecticide treated bed nets
• Protection against vitamin A and iodine
deficiencies.
Birth Preparedness and Complication Readiness:
• Approximately 15 percent of women develop a life-threatening
complication, so every woman and her family should have a plan for the
following:
• A skilled attendant at birth
• The place of birth and how to get there including how to obtain emergency
transportation if needed
•Items needed for the birth
•Money saved to pay the skilled provider and for any needed
mediations and supplies
•Support during and after the birth (e.g., family, friends) •
Potential blood donors in case of emergency.
The essential elements of a focused approach to antenatal care can
be summarized as:
• Identification and surveillance of the pregnant woman and her
expected child
• Recognition and management of pregnancy related complications,
particularly preeclampsia
•Recognition and treatment of underlying or concurrent illness
•Screening for conditions and diseases treatments such as
anemia, STIs (particularly syphilis), HIV infection,
mental health problems, and/or symptoms of stress or
domestic violence.
Delivery Care
•Normal birth is defined as Spontaneous in onset, low
risk at start of labor and remaining so throughout labor
and delivery.
•The infant is born spontaneously in the vertex position
between 37-42 completed weeks of pregnancies.
•After birth, mother and baby (child) are in
good condition. Describes as the process by
which the fetus, placenta with its membrane
is expelled through birth canal.
Aims of delivery care are to achieve:
• A healthy mother and child with the least possible level of
intervention
• Early detection and management of complications
• Timely referral of obstetric emergencies (if any) to a level
where it can be managed appropriately.
Recommended ways to increase skilled birth attendance
• Increase the number of professionals with midwifery skills in underserved
regions.
• Train, authorize and equip midwives, nurses and community physicians to
provide all feasible obstetric services needed within communities, especially
emergency interventions and to prescribe medications.
Postnatal Care
• The postnatal period is the period when most maternal deaths occur
compared to the antepartum and intrapartum periods. Post-natal care is
the care provided to the woman and her baby during the six weeks’
period following delivery in order to promote healthy behavior and
early identification and management of complications.
Reasons for low utilization rates for maternal health
services
• No physical access
• High costs
• Poor information
• Cultural preferences
•Lack of decision-making power by women
• Poor quality of care
• Delays in referring women from community
health facilities to hospitals
Essential Newborn Care
• Any intervention to prevent fetal deaths must focus on the mother,
since direct causes of neonatal deaths such as asphyxia, respiratory
distress syndrome and sepsis are related to the health or care of
the mother. The majority of neonatal deaths (around 66%) occur in
the first week of life.
You are expected to provide the following essential newborn care
during this period:
• Initiation of breathing and resuscitation when needed
• Cleanliness
• Prevent heat loss, (Warming and drying of baby and keeping the
delivery room warm)
•Early breast-feeding
•Eye care
•Management of newborn illness
•Immunization
•Vitamin K administration.
Maternal Nutrition
Poor nutrition before and during delivery contributes
in a variety of ways to poor maternal health, obstetric
problems and poor pregnancy outcomes.
1. Stunting - exposes women to the risk of
cephalopelvic disproportion.
2. Anemia- the cause may be due to inadequate intake of iron, parasitic
infestation and malaria. Women with severe anemia are therefore, more
vulnerable to infection and at increased risk of death due to obstetric
hemorrhage.
3. Severe vitamin A deficiency may make women more vulnerable to
obstetric complications, including infection and associated maternal mortality.
- A diet of pregnant and non-pregnant women should
contain daily allowance of Vitamin A of 800mg. It is
good to advice for women to have dark green, yellow or
orange fruits and vegetables, liver as a source of vitamin
A.
- It is recommended to give supplemental vitamin A to
pregnant and lactating women 200,000IU during pregnancy
and 500,000IU during breast feeding. But remember, high
doses of vitamin A during pregnancy causes teratogenic effect
on fetus (consider doses higher than 50,000 IU is toxic).
4. Iodine deficiency increases the risk of stillbirth and
spontaneous abortion in severely deficient areas in country like
Ethiopia. It also contributes to maternal death through
hypothyroidism. The daily allowance of iodine is 150 mg and
175 mg for non-pregnant and pregnant women respectively.
Diets containing iodine such as iodized salt and seafood’s
should be encouraged.
5. Folate Periconceptional folate supplementation
has a strong protective effect against neural tube
defects. Information about folate should be made
more widely available throughout the health and
education systems.
Estimation of maternal mortality
Definitions and measures of maternal mortality
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.
•According to ICD-10, maternal deaths should be divided
into two groups:
Direct obstetric deaths are those resulting from obstetric
complications of the pregnancy state (pregnancy, labor and the
puerperium), from interventions, omissions, incorrect
treatment, or from a chain of events resulting from any of the
above.
Indirect obstetric deaths are those resulting from
previous existing disease or disease that developed
during pregnancy and which was not due to direct
obstetric causes, but was aggravated by physiologic
effects of pregnancy.
