Maternal and child health: improving outcomes and reducing mortality rates

MAHAM RASOOL

NATIONAL LIRARY OF MEDICINE

Writer bay

2-28-2024
 Maternal and child health: improving outcomes and reducing mortality rates

Reducing Maternal Mortality and Morbidity

According to recent estimates, each year more than 500,000 women between the ages of 15 and 49 die of

causes related to pregnancy and childbirth—a leading cause of death among women in that age group

(Hill et al., 2001; World Health Organization, 1999; Murray and Lopez, 1997; Weil and Fernandez,

1999). Almost all maternal deaths (99 percent) occur in the developing world (World Health Organization

and United Nations Children's Fund, 1996; AbouZahr et al., 1996), and more than half occur in Africa

(Hill et al., 2001). The vast majority of these deaths are preventable. Researchers also estimate that more

than 40 percent of pregnant women experience obstetric disorders that are not immediately fatal (Weil

and Fernandez, 1999). Approximately 15 percent of all births are complicated by a potentially fatal

condition that requires emergency care (World Health Organization, 1999).

When mothers are malnourished or ill, or when they receive inadequate maternity care, their children also

face high risks of disease and death (Tinker, 2000). Tinker (1997) estimates that 30 to 40 percent of infant

deaths (1.5-2.5 million) could be averted by maternal interventions alone. This burden of death and illness

is borne not only by women and their children, but also by the families and communities that depend

upon them (Royston and Armstrong, 1989). For women of child-bearing age (15-44), maternal disorders

are the leading causes of death, accounting for almost 16 percent of deaths in this age group (Murray and

Lopez, 1997).

According to the International Classification of Diseases (ICD)-10 definition, maternal death is “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” (World Health Organization, 1999). The most frequently

cited measure of maternal mortality, known as the maternal mortality ratio (sometimes mistakenly

referred to as a “rate”), is the number of maternal deaths in a population that occur during a given year per
100,000 live births. This number, which represents the risk associated with a single pregnancy, differs by

a factor of more than 100 between the highest- and lowest-mortality settings and varies widely among

developing countries (see Tables 2-1a and 2-1b) (World Health Organization, United Nations Children's

Fund, United Nations Population Fund, 2001).

TABLE 2-1a
Maternal Mortality Ratio, Maternal Deaths, and Lifetime Risk of Maternal Death: World and
Regional Estimates (UNICEF classification of countries used [see Table 2-1b].).

TABLE 2-1b
Countries Grouped by UNICEF Regions.
Another useful measure of maternal mortality is lifetime risk—the odds that a woman in a given

population will die as a result of pregnancy. In Eastern Africa, as many as 1 woman in 11 dies of

pregnancy-related causes, as compared with as few as 1 in 4000 in Western Europe and 1 in 3,500 in

North America (World Health Organization, United Nations Children's Fund, United Nations Population

Fund, 2001). Table 2-1a lists regional and global estimates of the maternal mortality ratio, total annual

maternal deaths, and lifetime risk of maternal death. It is important to note that these numbers represent

crude estimates at best, since in the regions where the problem of maternal mortality is most acute, it is

least likely to be measured accurately (World Health Organization, United Nations Children's Fund,
United Nations Population Fund, 2001; World Health Organization, 1999). The same caveats apply to

estimates of maternal morbidity, which has been reported to occur in up to 30 women for every 1 woman

who dies from maternal conditions (Donnay, 2000). In the developing world, one in four women suffers

from acute or chronic disability related to pregnancy (Donnay, 2000; World Bank, 1999). Surveillance of

maternal mortality, along with other pregnancy and birth outcomes, is discussed in detail in Chapter 5.

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CAUSES OF MATERNAL MORBIDITY AND MORTALITY

The five most important direct causes of maternal mortality in developing countries are hemorrhage,

sepsis, unsafe abortion, eclampsia, and obstructed labor (Figure 2-1). Together these causes account for

more than two-thirds of maternal mortality in the world. Indirect causes of maternal death, which are

responsible for approximately 20 percent of maternal mortality worldwide, include preexisting conditions

such as malaria and viral hepatitis that are exacerbated by pregnancy or its management (World Health

Organization, 1999).

FIGURE 2-1
Global estimates of the causes of maternal deaths. SOURCE: World Health Organization, 1999.

Hemorrhage
Hemorrhage—primarily postpartum hemorrhage (PPH)—is the leading contributor to maternal mortality

worldwide, causing about 24 percent of all maternal deaths (World Health Organization, 1999). In some

regions, such as certain Chinese provinces, hemorrhage is reported to account for nearly half of all

maternal deaths (Kwast, 1991a). In Indonesia, excessive postpartum bleeding (self-reported) occurs in 7

percent of live births (Central Bureau of Statistics et al., 1995).

PPH is the excessive loss—usually of 500 milliliters or more—of blood from the genital tract within 24

hours of delivery (World Health Organization, 1998). If uncontrolled, hemorrhage can quickly lead to

shock and death, which generally occurs within 7 days of childbirth. Because of the difficulty of

measuring blood loss, a more practical definition of PPH is any blood loss that causes a physiological

change such as low blood pressure that threatens a woman's life (McCormick et al., 2002). Immediate

PPH is most commonly due to uterine atony, inadequate contraction of the uterus, and a retained placenta

or placental fragments (McCormick et al, 2002). Other causes include damage to the genital tract such as

cervical tears, perineal lacerations, and episiotomy. Even relatively mild PPH can aggravate existing

anemia caused by poor nutritional intake of iron and folate, hookworm infestation, malaria, or repeated

short birth intervals. Women who survive hemorrhage frequently suffer from chronic anemia.

Severe anemia, common in developing countries, contributes to high mortality from postpartum

hemorrhage. Delivery at home without a skilled birth attendant can result in long delays in obtaining

emergency treatment. When the first measures such as use of drugs to stop the bleeding or bimanual

compression of the uterus are not taken or are not effective, uterine artery ligation or hysterectomy may

be needed, both of which require access to comprehensive essential care services that may involve

significant expense and travel. When blood transfusions are required, women are exposed to the risk of

infection with HIV, hepatitis B, C, and D, malaria, syphilis, cytomegalovirus, and other agents if blood

supplies are unscreened and unsafe.

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INFECTIONS1

Sepsis
The second leading cause of maternal mortality, sepsis, is estimated to cause 15 percent of all maternal

deaths worldwide (World Health Organization, 1999). Puerperal infections are caused by transfer of an

infectious agent from the cervix or vagina to the uterus during labor or pelvic examination or by transfer
of bacteria from skin, nostrils, and perineum by contaminated fingers or instruments (AbouZahr et al.,

1998). The risk of puerperal sepsis is higher for women with sexually transmitted and other infections,

premature rupture of membranes, retained products of conception, diabetes, cesarean or other operation,

postpartum hemorrhage, anemia, poor nutritional status, history of previous complications of labor, and

poor infection control.

The most common sign of puerperal infection is fever, but a small percentage of women with postpartum

fever may have an infection at another site or no infection. Coupled with the unavailability and

inappropriate use of effective antibiotics, relatively minor puerperal infections can rapidly become life-

threatening. Women who survive puerperal sepsis are frequently left to cope with chronic ill health due to

pelvic pain, dysmenorrhoea, menorrhagia, and/or infertility (AbouZahr et al., 1998). Information on the

incidence and outcome of puerperal sepsis is limited because the majority of women in developing

countries deliver at home or are in a clinic or hospital only briefly.

Malaria
More than 40 percent of the world's population lives in malarious areas, and 90 percent of the estimated

300 to 500 million malaria cases occur in sub-Saharan Africa (United Nations Children's Fund, 2000).

Malaria in pregnancy has serious health consequences for the newborn, as well as for the mother (see

Chapters 3 and 6). Women are more susceptible to malaria infection during pregnancy, but this

susceptibility decreases with successive pregnancies (Duffy and Fried, 1999; Miller and Smith, 1998;

Brabin, 1983). Where malaria is endemic, adults rarely experience severe illness; however, pregnant

women in these populations are at increased risk for high parasitemias and anemia (Miller and Smith,

1998; Diagne et al., 1997). In areas of low malarial transmission, immunity is low, and infection during

pregnancy can cause severe disease, including fever and central nervous system complications (Steketee

et al., 1996a). HIV infection appears to interfere with the maintenance of pregnancy-specific immunity

acquired during first and second pregnancies, placing HIV-positive multigravidae in endemic areas at

increased risk for the clinical consequences of malaria (Steketee et al., 1996b; Verhoeff et al., 1999).
 Viral hepatitis
Viral hepatitis is the most common cause of liver disease during pregnancy (Pastorek, 1993). The disease,

which is caused by several diverse types of virus, is endemic in many regions of Asia, Africa, the Middle

East, and Central America where sanitation practices are inadequate (Michielsen and Van Damme, 1999).

One form of the disease, hepatitis E, is of greatest concern during pregnancy because of its reported

mortality rate of up to 25 percent among pregnant women, compared with a rate of less than 1 percent

among the general population (Skidmore, 1997; Aggarwal and Krawczynski, 2000). Pregnant women

who contract hepatitis E during the third trimester appear highly susceptible to developing a fulminant

infection. Even when the mother escapes liver failure, this infection often causes a fetal death (Michielsen

and Van Damme, 1999).

Unsafe Abortion
WHO estimates that about one-quarter of all pregnancies end in abortion, a total of 50 million per year.

Of these abortions, an estimated 20 million are performed with unsafe methods, by untrained providers,

or by the woman herself (Berer, 2000). About 90 percent of unsafe abortions worldwide occur in

developing countries (World Health Organization, 1994a), but there is substantial regional variation in

abortion-related mortality, as shown in Figure 2-2. In some areas of Africa, where unsafe abortion exacts

the highest death toll, it has been found to contribute to between 20 and 50 percent of maternal mortality

(Rogo et al., 1999; Benson et al., 1996; Okonofua, 1997).

FIGURE 2-2
Global estimates of maternal mortality due to unsafe abortion. SOURCE: Wulf, 1999.
Unsafe abortion can lead to a variety of complications, including sepsis, hemorrhage, genital and

abdominal trauma, tetanus, perforated uterus, and poisoning from abortifacient medicines (Maine et al.,
1994; Bernstein and Rosenfield, 1998; Brabin et al., 2000; Rochat and Akhter, 1999). These

complications have been estimated to result in at least 70,000 maternal deaths per year, accounting for at

least 13 percent of all maternal mortality (Bernstein and Rosenfield, 1998; Maine et al., 1994). Moreover,

the treatment of abortion complications consumes a disproportionate share of limited health care

resources in developing countries (AbouZahr and Ahman, 1998). For example, in Bolivia in the late

1980s, treatment of abortion complications was reported to consume 60 percent of national spending for

obstetric and gynecological care (Maine et al., 1994).

Hypertensive Disease of Pregnancy

Eclampsia is estimated to cause approximately 12 percent of all deaths due to pregnancy-related causes in

developing countries (World Health Organization, 1999). A review of hospital-based studies on maternal

mortality associated with hypertensive disorders in Africa, Asia, Latin America, and the Caribbean

revealed similar rates—between 10 and 15 percent of all maternal deaths—among all regions. In

Pakistan, where maternal mortality due to eclampsia has reached an estimated 500 deaths per 100,000 live

births, a hospital-based study showed eclampsia to occur in 1 of every 60 deliveries (Jamelle, 1997).

Several studies suggest that mortality associated with hypertensive disease of pregnancy is more difficult

to prevent than deaths due to other pregnancy-related causes (Duley, 1992; Moodley, 1990; Loudon,

1991).

Obstructed Labor
Obstructed labor is estimated to cause 8 percent of all maternal deaths and also presents serious risks for

the fetus and neonate (World Health Organization, 1999). Its incidence varies widely and is particularly

high where levels of nutrition are poor and early marriage is common (Kwast, 1992; Konje and Ladipo,

2000). Obstructed labor can often be anticipated, as it is caused by mechanical factors. Women whose

growth has been stunted by malnutrition or untreated infection or who bear children before pelvic growth

is complete are at greatest risk for cephalopelvic disproportion, disproportion between the size of the
infant's head and the bony birth canal, which is the main cause of obstructed labor; fetal malpresentation

is another, less common cause (Kwast, 1992).

Prolonged obstructed labor may produce injuries to multiple organ systems, such as vesico-vaginal or

recto-vaginal fistulae, and is associated with increased risk of sepsis, hemorrhage, and uterine rupture

(Arrowsmith et al., 1996; Konje et al., 1992). In the developing world, women who suffer physical

injuries with long-term sequelae resulting from prolonged obstructed labor may also face serious social

problems, such as divorce; exclusion from religious and other social activities; and ultimately, worsening

poverty and malnutrition (Arrowsmith et al., 1996).

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INTERVENTIONS
The Safe Motherhood Initiative was launched in 1987 as an inter-agency, international partnership

intended to raise awareness of the scope and consequences of poor maternal health in developing

countries and provoke action to address the issue of maternal mortality. Through these efforts, access to

safe pregnancy and childbirth is beginning to be viewed not just as a public health concern, but as a

human right (Thompson, 1999). Yet after more than a decade of increased attention to maternal deaths in

the developing world, maternal mortality ratios are essentially unchanged (World Health Organization,

United Nation's Children's Fund, 1996). This outcome, which stands in stark contrast to the success of the

Child Survival Initiative, resulted in part from a lack of strategic focus in the Safe Motherhood Initiative

(Maine and Rosenfield, 1999; Weil and Fernandez, 1999). See Chapter 1 for a discussion of the history of

the Safe Motherhood and Child Survival Initiatives.

Maternal health has yet to be perceived as a global priority (Graham, 2002). It is estimated that maternal

health services account for 5 to11 percent of total donor contributions to the health sector in developing

countries, and 4 to 12 percent of domestic health expenditure (Borghi, 2001). Today the challenge is to

provide essential maternal care, consisting of interventions that are most likely to reduce maternal deaths
and promote maternal health. Many such interventions, described in the remainder of this chapter, are

known to improve fetal and neonatal survival as well, as depicted in Figure 2-3.

FIGURE 2-3
Health care decisions for improved birth outcomes.

Interventions Involving Behavioral Change

Reducing risks for maternal, neonatal, and fetal mortality frequently involves behavioral changes for

women. While such changes are often difficult to achieve, they can be facilitated with information about

pregnancy, risks, and healthy behaviors (Harrison, 1997). Some examples of behavioral changes in

women that are discussed in this report include not reproducing after age 35; eating a healthy diet;

limiting or avoiding alcohol consumption; stopping smoking; using a bednet to protect against malaria;

arranging for a skilled birth attendant at labor and delivery; and recognizing and acting promptly on signs

of a complicated delivery.

Strategies that improve birth outcomes in monitored clinical trials may fail when introduced into large,

unmonitored populations if compliance with the intervention is inadequate. As a result, the

recommendations in this report focus on strategies that have proven effective in both clinical trials and in

large comparable populations. Research that identifies additional strategies for encouraging healthy

behaviors can contribute significantly to the success of health interventions that rely on patient

compliance over time. Such efforts might involve education of women through campaigns and advice or

counseling during antenatal care. They might also involve the development and showing of movies that

initiate changes in social behaviors.

Antenatal Care
Many antenatal interventions have been shown to reduce neonatal morbidity and mortality (Bergsjo and

Villar, 1997); however, evidence for the effectiveness of antenatal care in reducing maternal mortality

(and to a lesser extent, morbidity) is less compelling (McDonagh, 1996). Therefore the main discussion of

antenatal care will be presented in Chapter 3 of this report, which concerns the neonate.

It is widely accepted that screening pregnant women to identify those at risk for obstetric complications is

not a replacement for skilled care during labor and delivery. More maternal deaths occur in the much

larger group of low-risk women. As a result, antenatal care will not necessarily prevent complications

from occurring (Maine and Rosenfield, 1999). This was demonstrated in a study in Gambia in the early

1980s in which a relatively high standard of antenatal care was not able to identify the specific risk

factors that could predict which women were more likely to experience fatal complications (Greenwood

et al., 1987). In addition, those who did experience complications were often located too far from a

competent medical facility to receive treatment. As a result, maternal mortality remained extremely high

at 2,000 deaths per 100,000 live births (Greenwood et al., 1987).

Where adequate medical care is available, however, certain antenatal interventions appear to be effective

in reducing adverse maternal outcomes (Carroli et al., 2001; Villar and Bergsjo, 1997). These include the

recognition and treatment of hypertensive disease of pregnancy, detection and treatment of asymptomatic

bacteriuria, and external cephalic version at term (to prevent obstructed labor) (Carroli et al., 2001; Villar

and Bergsjo, 1997); more controversial are antenatal interventions to prevent maternal anemia and other

forms of nutritional supplementation. In addition to the potential for reducing specific causes of maternal

morbidity and mortality, antenatal care can also encourage birth preparedness and the use of skilled

assistance in labor and delivery.

 Recognition of hypertensive disease in pregnancy
A variety of symptoms may occur in women with pre-eclampsia, including headache, edema, visual

disturbance, abdominal pain, and nausea. Any of these symptoms warrants a blood pressure check and

screening for proteinuria (Walker, 2000). Recording of blood pressure at every antenatal visit is

recommended so that hypertensive disease in pregnancy can be recognized and treated before symptoms

develop and to prevent eclampsia. A dipstick test for proteinuria is also recommended at the first visit for

all women and at subsequent visits for all nulliparous women and those with previous preeclampsia or

hypertension (Villar and Bergsjo, 1997). Antihypertensive treatment for women with mild to moderate

hypertension during pregnancy remains controversial (Magee and Duley, 2001). The management of

hypertensive disease in pregnancy is addressed in a subsequent section.

Detection and treatment of asymptomatic bacteriuria

Routine screening for and treatment of asymptomatic bacteriuria has been shown to be cost-effective

(Rouse et al., 1995). Antibiotic treatment prevents pyelonephritis and may also reduce the risk of preterm

delivery (Smaill, 2001).

Prevention and treatment of malaria

Pregnant women who live in malaria-endemic areas need access to prevention and/or treatment of malaria

and associated anemia. The Cochrane Library has reviewed trials on the effectiveness of prompt treatment

of malaria infection, prophylaxis with antimalarial drugs to prevent parasitemia, and reduced exposure to

infection by using insecticide-impregnated bednets (Garner and Gülmezoglu, 2000). Prophylaxis with

antimalarials is clearly associated with a reduced frequency of disease— lower antenatal parasitemia,

lower malarial infection, less anemia, and fewer episodes of fever, and fewer low birth weight infants and

preterm births. A recent study in the Gambia (Okoko et al., 2002) adds to the Cochrane review, findings

in Ghana published 20 years earlier (McGregor et al., 1983), and findings in other African settings

(Garner and Brabin, 1994; Steketee et al., 2001) that intermittent preventive treatment with antimalarials
confirms these findings. Intermittent preventive treatment has several advantages: it is easier to sustain

over time, more cost-effective, and less likely to cause resistance to antimalarial drugs. The 20th WHO

Expert Committee Report recommends an effective one-dose regimen for women in malaria-endemic

areas who are in their first and second pregnancies (Steketee, 2002). Sulfadoxine-pyrimethamine is

effective in a single dose to semi-immune women, is not bitter, and is relatively well tolerated. In non-

African settings where malaria transmission is lower and Plasmodium vivax and multidrug resistant P.

falciparum coexist, finding an appropriate drug regimen is more difficult (Steketee, 2002).

Although insecticide-impregnated bednets have been shown to reduce malaria infection and death among

children (Binka et al., 1997; Lengeler, 2000), and are provided free of charge to pregnant women in

Kenya (Guyatt et al., 2002), their effectiveness in preventing malaria among pregnant women has not

been established. Further studies of bednets are warranted as bednet use requires considerable effort to

maintain good adherence and requires resources, yet has significant potential for pregnant women.

Prevention of anemia
Based on data from 1988, WHO estimates that 55 percent of all pregnant women living in developing

countries and 18 percent of those in developed countries have anemia, defined as a blood hemoglobin

concentration of less than 11 grams per deciliter (World Health Organization, 1992). The effects of

anemia on maternal mortality are less well understood. Reports from India, Kenya, Nigeria, and Malawi

identify anemia as the underlying cause of 8 to 16 percent of maternal deaths (AbouZahr and Royston,

1991). WHO estimates that one-tenth of maternal mortality in developing countries is atttributable to iron

deficiency (World Health Organization, 2002a). Another study concludes that a significant body of causal

evidence exists to suggest maternal mortality from severe anemia (Stoltzfus, 2001).

On the other hand, a critical review of existing research in this area concluded that the data available are

inadequate for determining the contribution of maternal anemia to maternal mortality (Allen, 2000).
Many factors may predispose a pregnant woman to become anemic, and their relative importance varies

by geographic area and by season (van den Broek and Letsky, 2000). The common causes include

nutritional deficiencies—iron, folate, and less often vitamin B12; blood loss (childbirth, hookworm

infestation); infections (malaria, HIV/AIDS); and genetic defects (sickle cell, α- and β-thalassemias, and

some metabolic disorders). In the developing world, nutritional iron deficiency appears to be the

predominant cause of anemia; other important causes include malaria and hookworm infection, as well as

other micronutrient deficiencies (Guidotti, 2000; van den Broek and Letsky, 2000).

Guidelines for developing countries compiled by WHO, UNICEF, and the International Nutritional

Anemia Consultative Group recommend that all pregnant women receive 60 mg of elemental iron and

400 micrograms of folic acid daily to reduce the prevalence of severe maternal anemia (van den Broek,

1998). The guidelines also advise prophylaxis against malaria and hookworm for anemic women in areas

where these infections are common. Although iron supplementation can prevent low hemoglobin at birth

and at 6 weeks postpartum, there is inconclusive evidence of a beneficial effect on pregnancy outcomes

for either mother or child (Mahomed, 2002; Sloan et al., 2002). A multicenter, double-blind, randomized

trial in Mexico observed a greater increase in hemoglobin levels in women receiving a daily supplement

of both iron (80 milligrams) and folate (370 milligrams) than of iron alone, but did not measure an impact

on birth outcomes (Juarez-Vazquez et al., 2002). Rigorous trials need to examine more successful

strategies for supplementing iron consumption in communities where iron deficiency is common and

anemia is a serious health problem (Mahomed, 2002).

Vitamin A supplementation
Studies conducted in Nepal indicate that vitamin A or β-carotene supplementation may reduce morbidity

and mortality in pregnant women related to night blindness, nausea, and length of labor (Christian et al.,

2000a, 2000b; West et al., 1999).

 Nutritional interventions
Widespread maternal malnutrition in developing countries has created a demand for nutritional

interventions. As noted in Chapter 1, malnourished mothers are at increased risk for complications and

death during pregnancy and childbirth. In addition, their children tend to have low birth weight, fail to

grow at a normal rate, and have higher rates of disease and early death (Tinker, 2000; United Nations

Administrative Committee on Coordination/ Sub-Committee on Nutrition, 1994). Evidence is insufficient,

however, with regard to the clinical efficacy and cost-effectiveness of nutritional supplementation

designed specifically to prevent maternal morbidity and mortality, particularly in comparison with other

interventions (Ladipo, 2000; Kulier et al., 1998; Rush, 2000). There is some concern that nutritional

programs divert resources from interventions that could be more effective in reducing maternal mortality

and morbidity (Rush, 2000). While it has been noted that past improvements in nutrition in Western

Europe had little effect on maternal mortality, these women were not as malnourished as the target

populations for contemporary nutritional programs (Loudon, 2000).

Prenatal counseling to recognize signs of complications

Since every pregnant, delivering, or postpartum woman is at risk for serious, life-threatening

complications, an important goal of antenatal care in developing countries should be to teach women and

their families to recognize signs of obstetric complications and respond promptly (Akalin and Maine,

1995). Signs and symptoms of pregnancy and labor complications are not always recognized as causes for

concern. In rural West African communities, for example, symptoms such as swelling of the feet (a

possible sign of pre-eclampsia), late-term spotting or bleeding (a sign of antepartum hemorrhage), and

long labors are not viewed as potential medical emergencies (The Prevention of Maternal Mortality

Network, 1992).
 Prenatal counseling to use a skilled birth attendant
Antenatal care can also contribute to successful pregnancy outcomes by encouraging women to obtain

skilled care for labor and delivery. According to WHO estimates, more than half of all women give birth

without the assistance and supervision of a skilled birth attendant (World Health Organization, 1997). A

study of 300 women from low- and middle-income families in urban India showed that those who

received a relatively high level of antenatal care were four times more likely than those who had little or

no antenatal care to deliver with a skilled attendant (Bloom et al., 1999). Antenatal care providers can

help women and their families find a place to give birth, a skilled attendant, and the essential items

necessary for a clean delivery. Planning for delivery should also anticipate complications and the need for

referral to an appropriate medical facility with the appropriate level of good quality essential obstetric

care. It may involve transport arrangements, emergency funds, a family member to accompany the

woman and assist in decisionmaking.

Skilled Attendance at Childbirth

There are two important challenges to achieving a significant reduction in maternal mortality: obtaining

skillful services from the birth attendant at labor and delivery and access to higher level obstetric care in

the event of complications (Weil and Fernandez, 1999; Koblinsky et al, 1999). Meeting these challenges

requires competent health professionals as well as an environment in which they can perform effectively

(Graham et al, 2001). This section discusses the evidence for the use of a skilled birth attendant during

childbirth.

According to a comprehensive definition of the “skilled birth attendant” given in a 1999 joint statement

by WHO, the United Nations Fund for Population Activities (UNFPA), UNICEF, and the World Bank

(World Health Organization, 1999), a skilled birth attendant is a person with midwifery skills, such as a

midwife, nurse, or physician, who has been trained to proficiency in the skills necessary to manage

normal labor and delivery. A skilled attendant recognizes the onset of complications, performs essential

interventions, starts treatment, and supervises the referral of mother and baby for interventions that are
beyond their competence or not possible in the particular setting. More detailed information on the

essential competencies of a skilled birth attendant is given in Appendix C.

There are major differences worldwide and among developing countries in the proportion of deliveries

with skilled attendance, the quality of that attendance, the proportion of deliveries that take place in health

facilities, and the quality of services in these facilities. There are also important differences in the risks for

maternal and neonatal mortality in different settings. In some urban areas of developing countries and in

all developed countries, most childbirth takes place in a hospital attended by a physician or midwife. In

developing-country urban areas, childbirth may also take place in the home with or without medically

trained attendants or in a health clinic with a nurse or physician. In rural areas of the developing world,

most childbirth takes place at home, generally without skilled birth attendance, and often with poor access

to medical care.

What is the evidence that skilled attendance at childbirth reduces mortality?

For an issue as important as the role of skilled attendance, it might be assumed that randomized,

controlled trials would have been undertaken in a range of low- and middle-income settings. Such

rigorous trials are particularly challenging (Safe Motherhood Inter-Agency Group, 2000), however, and

have not been done. The appropriate outcomes—maternal, neonatal, and fetal mortality—are able to be

measured, but since maternal mortality is a relatively rare event, obtaining an accurate estimate of the

effectiveness of skilled attendance at childbirth on reducing maternal mortality would require a very large

population study. The individual follow-up of each pregnancy adds an additional complication to a very

large trial (compared with simpler interventions such as mass vaccination). Such a trial may also have

ethical issues involving the withholding of skilled birth attendance from a population of women who are

serving as controls in the trial. The result of the cost and complexity of conducting a rigorous trial is that

only now—in 2003—is the first discussion of rigorous studies, possibly randomized, controlled trials

(RCTs), underway by Initiative for Maternal Mortality Programme Assessment (IMMPACT). It is

anticipated that this program will address measurements of maternal, neonatal, and fetal mortality, will
undertake rigorous trials on the effectiveness of different strategies to reduce mortality and severe

morbidities during childbirth, and that these assessments will include the impact of skilled attendance.

There are serious difficulties to be addressed, such as how to randomize the women who are delivering to

trained and untrained attendants. Although rigorous cause and effect data are not available, the committee

has reviewed the wide range of less rigorous data that are currently available in order to address this

important issue. In the committee's judgment, skilled birth attendance has the best evidence so far for

reducing maternal and neonatal mortality.

Historical trends
Maternal mortality in 1870 in much of what is now the developed world exceeded 600 per 100,000 live

births, a figure comparable with current maternal mortality ratios in many developing countries (Safe

Motherhood Inter-Agency Group, 2000). Significant reductions in maternal mortality were accomplished

first in northwestern Europe (Sweden, Norway, Denmark, and the Netherlands) in the mid- to late-19th

century, and several decades later in Britain and the United States (Loudon, 2000). In the mid-18th

century, policy-makers in Sweden concluded—on the basis of newly collected vital statistics—that

maternal mortality could be greatly reduced if all births were attended by qualified midwives (Högberg et

al, 1986). The country actively recruited and trained midwives, and, over the course of more than a

century, developed a cadre of largely autonomous midwives who worked under the supervision of local

physicians (Van Lerberghe and De Brouwere, 2001). Between 1860 and 1900, the percentage of

deliveries in Sweden attended by certified midwives increased from 40 to 78 percent, while the maternal

mortality rate declined by more than 40 percent (Van Lerberghe and De Brouwere, 2001). This was in

marked contrast to the United States, where skilled birth attendance was not promoted and maternal

mortality remained at 800 per 100,000 live births (Van Lerberghe and De Brouwere, 2001). Figure 2-

4 shows the decrease in maternal mortality in Sweden between 1870 and 1900 considered (but not

proven) to be due to the effectiveness of skilled attendance at childbirth. It also shows a second phase of

decreasing maternal mortality for about 30 years beginning in 1937, which is considered to be the result
of a series of medical advances—cesarean section, penicillin, blood transfusion, institutional delivery, and

antenatal care.

FIGURE 2-4
Maternal mortality in Sweden 1751-1980. NOTES: CS is cesarean section.

Epidemiological trends
National percentages of childbirths assisted by a skilled birth attendant are shown with corresponding

maternal mortality ratio (MMR) and infant mortality rate2 (IMR) data in Figures 2-5 and 2-6 respectively.

Similar data are given by region in Table 2-2. Both MMRs and IMRs tend to be lowest where most

women give birth with a skilled attendant. In settings where a typical birth takes place at home, not

attended by a skilled birth attendant (World Health Organization, 1997), MMRs and IMRs tend to be

highest. The associations of skilled care with reduced maternal and infant mortality appear to be strong.

Again caution is appropriate in drawing inferences about causality from these associations as other factors

could also be involved. In assessing the reliability of the data, it is necessary to consider the problems

involved in estimating maternal and neonatal mortality and coverage by skilled attendants. The definition

of skilled attendant may vary with country and setting, the effectiveness of attendants varies with their

support in terms of supplies and equipment, access to strong referral facilities, their abilities at convincing

patients to be referred and accomplishing that in time to influence the outcome, and their oversight and

continuing training. The data available aggregates skilled care provided by physicians, nurses, and

midwives, which may distort the results that would be observed for midwives alone. Finally,

measurement of the association of skilled attendance with neonatal, not infant mortality—almost two-

thirds of which is neonatal—would be more specific and therefore more accurate.

 FIGURE 2-5
Association of maternal mortality ratio and delivery by a skilled birth attendant. NOTES: Bars:
Percent of births with skilled attendance. Line: Maternal mortality rate.

FIGURE 2-6
Association of infant mortality rates and delivery by a skilled birth attendant. NOTES: Bars:
Percent of births with skilled attendance. Line: Infant mortality rate.

TABLE 2-2
Maternal and Neonatal Mortality Compared with Rates of Skilled Care and Use of Health
Facilities for Childbirth.

Provision of clinical strategies during childbirth

Clinical strategies to address childbirth and its complications are identified in Chapters 2 to 4 of this

report. Providing a skilled birth attendant during childbirth who has the knowledge and experience to use

certain strategies when they are needed is a key step to reducing mortality and severe disability in
childbirth. The second key strategy is provision of good-quality obstetric care for complicated deliveries.

For many, childbirth proceeds normally and attendants can focus on the provision of safe and hygienic

care and guidance to new mothers on their care and the care of their infants. However, most

complications of childbirth cannot be predicted and, when they occur, having a skilled attendant at the

delivery is generally the only safe way to provide life-saving clinical strategies. An alternative strategy is

to provide broad access to basic or comprehensive essential obstetric care. This is more realistic in urban

than rural areas. However, even when higher-level care is very readily accessible, the birth attendant must

first recognize a complication and arrange an effective referral.

Although rigorous trials are not available at this time, the committee views the overall association of

skilled care with reduced mortality at childbirth, coupled with the need for a skilled birth attendant who

can apply the clinical strategies identified in this report when they are needed as sufficient grounds for

recommending that a skilled attendant assist at every birth. Providing every delivery with an attendant

who has certification in the essential skills, and also the necessary supplies and equipment, access to

essential obstetric and neonatal care for complications, an effective referral system, a regular caseload,

and appropriate accountability and oversight have been found to be effective in the countries with lower

maternal and neonatal mortality. Training a cadre of midwives to provide life-saving care for women

during childbirth and developing a strong network of essential care for referral of complicated deliveries

is a challenge that must eventually be addressed by all countries.

In most settings, traditional birth attendants (TBAs) are guided by traditional, often untested practices,

rather than medical experience. They generally do not carry a regular caseload and do not therefore have

the opportunity to build the experience of a nurse or midwife. Many TBAs have received training on safer

birth practices, including clean delivery and avoidance of harmful practices. However, they have not been

effective in reducing mortality during childbirth. Managing normal deliveries, recognizing complications,

and managing and referring patients with complications requires more knowledge, training, and oversight,

as well as the ongoing experience that is gained from a regular caseload. Since TBAs are trusted and
respected in their community, they can provide comfort for the mother and family during labor and

delivery and introduce and facilitate the work of a midwife in the community, but they should not be seen

as a substitute for a skilled birth attendant.

In some settings, auxiliary nurse/midwives, community midwives, village midwives, and health visitors

have received some training in childbirth skills. These workers may have more education, training, and

supervision than TBAs, and (unlike some midwives) live in and know the community, and be less

expensive in both their training and continuing compensation. Despite the attractiveness of an apparently

less expensive option, the ability of attendants without the skills and experience of a skilled birth

attendant to reduce maternal, neonatal, and fetal mortality must be established in trials in similar settings

before being adopted for a wider population.3

Management of Childbirth

The first stage of labor

In order to prevent maternal mortality and morbidity associated with prolonged labor, the progress of

labor should be monitored. Simple and effective monitoring of labor was first used in Zimbabwe in the

1970s (Philpott and Castle, 1972a; Philpott and Castle, 1972b). This involved graphically tracking

cervical dilation over time. A refined version of the initial device, known as the partograph, is now widely

used to reduce maternal and fetal morbidity due to prolonged or obstructed labor. The central feature of

the partograph is a graphical representation of the progress of labor—cervical dilatation, descent of

presenting part, and duration and frequency of contractions—and its relationship to maternal and fetal

condition (see Box 2-1). The pattern of cervical dilatation in normal labor among different ethnic groups

is so similar that a partograph is useful throughout the world (Lennox and Kwast, 1995).
 BOX 2-1
Monitoring Labor with the Partograph. The partograph is intended for use by health workers
trained in childbirth who can observe and conduct normal labor and delivery, perform vaginal
examinations, and assess and accurately plot cervical dilation on a (more...)
In the early 1990s, a partograph produced and promoted by WHO was tested in a multicenter trial in

Southeast Asia involving 35,484 women (World Health Organization, 1994b). Based on the encouraging

results of this trial, WHO recommends widespread use of the partograph. The partograph was revised in

2002 (Figures 2-7a and 2-7b). When used at a health center or maternity center, the device provides an

early warning that labor is likely to be prolonged, and the woman should be transferred to a hospital. In

the hospital, it can provide a warning that extra vigilance or an emergency procedure, such as cesarean

section, is needed. Use of the partograph has been reviewed by the Cochrane Database of Systematic

Reviews (Buchmann et al., 2002). It has been found to assist labor management by clearly indicating

departures in the progress of labor and anticipating interventions before complications occur.

Interventions that may prevent mortality or serious morbidity for mother or fetus include labor

augmentation, cesarean section, or transfer to a more sophisticated facility. The Cochrane review does

caution against assuming that all women will progress through labor at the same rate. This assumption

could have adverse effects such as increased rates of artificial rupture of the membranes, oxytocin

augmentation, and use of analgesia. Despite its effectiveness, however, the partograph has not been

universally adopted. A recent survey of 420 physicians and midwives in Enugu, Nigeria, revealed that

although about 90 percent of respondents had heard of the partograph, only about 25 percent used it

(Umezulike et al., 1999). Introduction of the partograph needs to be accompanied by training in its use

with appropriate supervision and follow-up.

The second stage of labor

A recent review of clinical trials concludes that an inadequate number of methodologically stringent

comparisons of labor positions have been conducted to allow recommending one position over another;

thus women should be encouraged to give birth in the position they find most comfortable (Gupta and
Nikodem, 2000). Sustained, early bearing down may slightly decrease the duration of the second stage of

labor, but can result in maternal exhaustion and compromised maternal-fetal gas exchange (Mayberry et

al., 1999/2000). Several brief periods of breath holding and bearing down during each contraction, which

tend to occur spontaneously, appear to be safer for the fetus than Valsalva-type extended pushing with

sustained breath holding (Sleep et al., 1989; Mayberry et al., 1999/2000).

Episiotomy is used in many deliveries for first-time mothers despite the fact that there is little evidence to

support the frequent use of this technique (Sleep et al., 1989). In fact, episiotomies have been shown in

some cases to cause an increase in the rate of perineal trauma (Moller Bek and Laurberg, 1992).

Active management of third-stage labor

Delivery of the placenta and membranes is a particularly hazardous part of childbirth for mothers,

because of the risk of postpartum hemorrhage (PPH). Active management involves three steps to augment

uterine contractions and prevent PPH due to uterine atony: (1) give a uterotonic drug within one minute of

birth; (2) clamp and cut the umbilical cord soon after birth; and (3) deliver the placenta by controlled cord

traction and counter pressure on the uterus through the abdomen (McCormick et al., 2002).

Three large RCTs have compared postpartum hemorrhage and other outcomes in deliveries with active

management of the third stage of labor and those with physiologic management. These trials—undertaken

in Bristol (Prendiville et al., 1988), Hinchingbrooke (Rogers et al., 1998), and Abu Dhabi (Khan et al.,

1997)—have been reviewed by the Cochrane Library (Prendiville et al., 2001) and McCormick et al.

(2002). The components of active management in the three trials included a prophylactic oxytocic drug

during or after delivery of the anterior shoulder, immediate clamping of the umbilical cord, and delivery

of the placenta by controlled cord traction or maternal effort. Mothers in the physiologic management

group received no oxytocic drug in two trials and only after the delivery of the placenta in the third; no

cord clamping until the placenta was delivered, pulsation ceased, or the baby was delivered; and delivered

the placenta without assistance. In these RCTs, there was a significantly higher rate of postpartum
hemorrhage in the physiologic management group than in the active management group (17.9 vs. 5.9

percent, 16.5 vs. 6.8 percent, and 11 vs. 5.8 percent). Active management thus reduced the need for blood

transfusion, the occurrence of a prolonged third stage, and the need for additional uterotonic drugs. There

was no difference between the two groups in blood pressure or need for manual removal of retained

placenta. The maternal position (upright or supine) did not influence PPH in either group, and neonatal

outcomes were not affected by the management of delivery. Giving a uterotonic drug immediately after

birth rather than after the placenta is delivered was shown in the Abu Dhabi trial to provide the greatest

reduction in PPH. When the placenta was delivered by maternal effort, use of oxytocin reduced the risk of

PPH, shortened the time for the third stage of labor, raised hemoglobin levels at 48 hours postpartum, and

did not increase the risk of retained placenta.

Currently, oxytocin or syntometrine (oxytocin and ergometrine) are the prophylactic drugs of choice to

prevent postpartum hemorrhage (Rogers et al., 1998). The Cochrane Library (McDonald et al., 2000) and

McCormick et al (2002) have reviewed several RCTs comparing oxytocin and syntometrine (oxytocin

and ergometrine) for their effectiveness in the active management of third-stage labor. While one study

showed syntometrine to produce a small but significant reduction in PPH compared with oxytocin

(McDonald et al., 2000), the latter was the preferred drug because ergometrine can raise blood pressure

and is, therefore, contraindicated for women with hypertensive disease of pregnancy, and it frequently

causes nausea and vomiting (El-Refaey et al., 2000). Both drugs require refrigeration and protection from

light to maintain their potency, and must be injected, which reduces their practicality in low-resource

settings. Increasing evidence indicates that oral or rectal misoprostol, an inexpensive, stable drug, shows

promise for reducing postpartum hemorrhage (Ng et al., 2001; Goldberg et al., 2001; Hofmeyr et al.,

1998; Surbek et al., 1999; Walley et al., 2000; Bamigboye et al., 1998; O'Brien et al., 1998).

Misoprostol4 is particularly suitable in developing-country settings where oxytocin and ergometrine are

unavailable.
 An essential package of interventions for care during labor and delivery
In conclusion, an essential package of interventions for care during labor and delivery should include the

following:

 Monitoring the progress of labor using a partograph

 Using aseptic practices
 Supporting the birthing position of the mother's choice
 Avoiding medical episiotomy unless specifically indicated
 Preventing postpartum hemorrhage through active management of the third stage of labor

Complications of labor and delivery and provision of essential obstetric care

Even when women receive the highest-quality antenatal care and have skilled providers at the delivery,

complications can arise and cause maternal, neonatal, or fetal death. The major causes of maternal

mortality described earlier in the chapter (hemorrhage, sepsis, unsafe abortion, hypertensive disease of

pregnancy, and obstructed labor) can be addressed by essential obstetric care (EOC) in developing county

settings (United Nations Children's Fund, World Health Organization, United Nations Population Fund,

1997). See Table 2-3.

TABLE 2-3
Essential Obstetric Care Services to Address Major Causes of Maternal Mortality.
Basic EOC involves six signal services: antibiotic, oxytocic, and anticonvulsant drugs; manual removal of

the placenta; removal of retained products of conception (by manual vacuum aspiration with a large

syringe); and performance of assisted vaginal delivery (manual assistance, vacuum extraction, or forceps

delivery). Other functions are also important, but for the purposes of monitoring, the six functions are

considered sufficient for most EOC activities.

These six services can prevent a large portion of obstetric deaths and can be carried out by a skilled

attendant in a clinic or community health center prepared with medication and intravenous fluid—if the

skilled attendant is trained and focused on the frequent direct causes of obstetric deaths. For some cases

of postpartum hemorrhage these services would be sufficient. Such a clinic can function as a referral site

for patients with these complications who have delivered at home or it can serve as a delivery site.

Massive hemorrhage or true obstructed labor will require a hospital facility with blood transfusion,

anesthesia, and the capacity for major surgery (cesarean delivery or hysterectomy.) Even then, basic EOC

can save women's lives by stabilizing them before referral and a journey that may take many hours

(United Nations Children's Fund, World Health Organization, United Nations Population Fund, 1997).

Comprehensive EOC involves the six basic services and two additional ones: the ability to perform

surgery, including administering anesthesia, and provision of blood transfusion.

In developing countries, women with complicated labors face many barriers to receiving timely and

appropriate medical care. These obstacles can be summarized as the following four delays (Lawn et al.,

2001), which have been adapted from the original three delays described by Thaddeus and Maine (1994)

and Maine (1997):

 Delay in recognizing complications

 Delay in deciding to seek care
 Delay in reaching a health facility because of a lack of transportation or resources
 Delay in receiving appropriate care at the facility
Significant reductions in maternal—as well as neonatal and fetal— mortality can be achieved if

complications are anticipated and addressed promptly. For example, a major reduction in maternal

mortality achieved over a 15-20 year period in a rural area of the Gambia has been attributed to a

combination of increased availability of emergency obstetric care, improved transport, and increased

communication (Walraven et al., 2000). These and other interventions to strengthen health care delivery,

which are critical to the success of any strategy to improve birth outcomes in developing countries, are
discussed in Chapter 5. The following section describes specific interventions to address major

complications of labor and delivery.

Management of postpartum hemorrhage requires vigilance to prevent and detect this frequently fatal

condition, as well as rapid response to address it when it arises. While the use of blood transfusions may

be limited to hospital deliveries, other interventions can be performed at peripheral health centers. These

include manual removal of the placenta; bimanual uterine compression; repair of cervical, vaginal, or

perineal lacerations; administration of parenteral oxytocics; and uterine massage.

The medications used to control postpartum hemorrhage in the United States include oxytocin (pitocin),

methylergonovine (Methergine), 15-methyl PGF (Hemabate), and Dinoprostone (Prostin E2).

Unfortunately, most of these require parenteral administration and/or refrigeration, 5 conditions that make

them unsuitable for use in many rural areas of developing countries. Misoprostol, discussed above as a

possible means of preventing postpartum hemorrhage as part of active management of third-stage labor,

also appears promising as a means of controlling hemorrhage, particularly in low-resource settings.

Unlike other oxytocic agents, misoprostol does not require refrigeration, an important advantage (O'Brien

et al., 1998).

Management of hypertensive disease in pregnancy aims to prevent the occurrence or recurrence of

convulsions, which can be life threatening. Magnesium sulfate has been used extensively in the United

States for the management and prevention of eclamptic seizures. Several studies, including a large

collaborative trial, have shown the drug to be superior to phenytoin and diazepam for seizure prevention

(See Box 2-2). Results of the collaborative trial suggest that magnesium sulfate confers additional

advantages for both mother and neonate (Eclampsia Trial Collaborative Group, 1995). While magnesium

sulfate has been viewed as a promising drug for low-resource settings because it is inexpensive and

relatively easy to produce, its delivery by intravenous drip or intramuscular injection restricts its use.
 BOX 2-2
Comparing Anticonvulsant Treatments for Eclampsia. In 1995, the results of an international
multicenter randomized trial enrolling nearly 1700 women offered the most compelling evidence
to date in favor of magnesium sulfate over diazempam or phenytoin (more...)
A recent review of randomized trials concluded that there is not enough evidence to establish the benefits

and hazards of anticonvulsants for women with pre-eclampsia (Duley et al., 2000). A trial involving

14,000 women is currently under way in the United Kingdom to further evaluate the benefits and risks of

treating pre-eclampsia with magnesium sulfate (Duley and Neilson, 1999). The Magpie Trial, a recent

international study involving 10,000 women, found that magnesium sulfate halved the risk of eclampsia

(Magpie Trial Collaborative Group, 2002). A review of the use of magnesium sulfate for pre-eclampsia

concludes that, “There is now international consensus that magnesium is the treatment of choice for

preeclampsia and eclampsia, but the mechanism underlying its salutary effect remains debatable”

(Greene, 2003).

Management of obstructed labor involves timely interventions, including vacuum extraction, forceps,

and cesarean section. These procedures, traditionally the domain of physicians, have been performed

successfully by trained medical assistants and nurses in Mozambique (Vaz et al., 1999) and Zaire (Duale,

1992), allowing such services to be maintained in rural areas. Mortality and complication rates for

cesarean sections performed by these workers were reported to be comparable to those performed by

physicians. This is a topic for further studies.

Prevention and management of maternal infection. Infection during labor and in the postpartum period

can be reduced through aseptic delivery practices and careful attention to risk factors for infection,

including excessive vaginal examinations, premature rupture of membranes, and prolonged labor.

Induction of labor in cases of uncomplicated prelabor rupture of membranes has been shown to reduce
maternal and neonatal infection (Tan and Hannah, 2000). The early detection of infection and the timely

use of antibiotics also reduce maternal morbidity and mortality (AbouZahr et al., 1998; Kwast, 1991b).

Prevention of abortion-related morbidity and mortality. Of the five major causes of maternal

morbidity and mortality discussed in this chapter, complications of abortion are the most amenable to

reduction through prevention—that is, through improved access to and use of contraception (Maine et al.,

1994; AbouZahr and Ahman, 1998). Better contraception would not only decrease the number of

unwanted pregnancies, but also reduce neonatal and fetal mortality and morbidity associated with closely

spaced births, multiparity, and maternal age. Unfortunately, many barriers restrict women's access to

family planning information and services. Even where family planning resources are readily available,

unwanted pregnancies occur as a result of failure to use contraception and contraceptive failure

(AbouZahr and Ahman, 1998; Henshaw and Kost, 1996).

Abortion tends to be vastly safer in countries where it is legal than where it is prohibited. Legalization of

abortion does not appear to increase abortion rates, but does reduce morbidity and mortality (Serbanescu

et al., 1995). Yet even where the procedure is legal, safe abortion may still be unavailable to many

women because of expense, distance, or social barriers (AbouZahr and Ahman, 1998).

Overused or Inappropriate Interventions

Interventions such as cesarean sections, episiotomies, and use of oxytocics in the early stages of labor

tend to be overused in some developing country settings, while they are not always available when

needed in other settings (Buekens, 2001). More than 15 percent of deliveries involve a cesarean section in

a majority of Latin American countries (Belizan et al., 1999) and in some regions of Asia (Buekens,

2001; Cai et al., 1998). Cesarean sections are less common in Africa, although they are used in more than

5 percent of deliveries in many urban areas of East and Southern Africa and in Ghana. In the poorest rural

areas of Africa, the problem is a lack of access to cesarean sections, which are done in less than 1 percent

of deliveries.
Episiotomies have become increasingly common, but a Cochrane review has found this increased use to

be without scientific justification (Carrolli and Belizan, 2000). More selective use of episiotomy causes

less posterior perineal trauma, reduced need for suturing, and fewer healing complications, but there is an

increased risk of anterior perineal trauma. Several studies have shown episiotomy rates in African

hospitals as high as 46 percent of all deliveries and 87 percent of primiparae deliveries. Similar high rates

have been reported in some Latin American countries (Buekens, 2001).

As discussed earlier in this chapter, the routine use of oxytocics during third stage labor has been found

beneficial (Prendiville et al., 2001). Use of oxytocin during the first and second stages of labor is,

however, controversial, especially in developing countries where it is may be administered

intramuscularly or with less control of the speed of infusion, which may hyperstimulate or cause uterine

contracture. Use of oxytocin during labor has been associated, in studies in West Africa and Nepal, with

increased risk of fetal distress and neonatal morbidity (Dujardin et al.,1995; Ellis et al., 2000).

Inappropriate interventions include pubic shaving, enema, and vacuum and forceps extraction. In settings

where the level of hygiene is less strong, vaginal examination is not appropriate, while in other settings

these should not be more frequent than necessary because of the risk of infection. Reducing both overuse

and inappropriate use of interventions during labor and delivery is best addressed by basing clinical

practice on a strong evidence base. This requires continuing evaluation of practices through randomized

controlled trials and comprehensive education of birth attendants through influential health leaders,

provision of educational materials, and audit and feedback (Buekens, 2001).

Go to:

RECOMMENDATIONS
A formidable barrier to improving birth outcomes in many developing countries is the social status of

women. Achievement of gender equity, and with it increased resources for primary health care, is a

certain but long-term means to improving women's reproductive health. More immediate reductions in
maternal mortality can be accomplished by addressing its most frequent causes: hemorrhage, hypertensive

disease of pregnancy, obstructed labor, sepsis, and unsafe abortion. Significant reductions in maternal—

as well as fetal and neonatal—mortality depend on broad access to essential life-saving services during

labor and delivery and immediately thereafter. This requires (1) a skilled birth attendant, and (2) access to

good-quality essential obstetric care in the event of complications.

Recommendation 1. Every delivery, including those that take place in the home, should be assisted

by a skilled birth attendant (a midwife, physician, or nurse) who has been trained to proficiency in

basic techniques for a clean and safe delivery, and recognition and management of prolonged labor,

infection, and hemorrhage. Where necessary, the birth attendant should also be prepared to

stabilize and swiftly refer the mother to a facility providing essential obstetric care. 6 (See Chapter

3 for the neonatal component to this recommendation.)

Recommendation 2. Essential obstetric care should be accessible to address complications of

childbirth that cannot be managed by a skilled birth attendant. This requires a network of good-

quality essential care facilities that provide basic essential obstetric care: administration of

antibiotic, oxytocic, and anticonvulsant drugs; manual removal of the placenta; removal of retained

products of conception; and assisted vaginal delivery. Comprehensive essential obstetric care

facilities have the capacity to perform these basic services and also surgery and blood transfusion.

Access for the majority of a population to the appropriate level of care also requires strong referral

systems that include communication with, and transportation to, referral facilities. (See

Chapters 3 and 5 for additional components to this recommendation.)

These two interventions, which represent the highest priority for reducing maternal mortality, should be

extended where possible by a program of postpartum maternal care addressing major causes of maternal

mortality and morbidity during the first month after childbirth.

Recommendation 3. Postpartum care is critical during the first hours after birth and important

throughout the first month. For the mother, such care should emphasize the prevention, timely

recognition, and treatment of infection; postpartum hemorrhage; and complications of

hypertensive disease of pregnancy. (See Chapter 3 for a neonatal component to this recommendation.)

While many of the benefits of antenatal care accrue to the fetus and neonate, certain preconceptional and

antenatal interventions can significantly reduce maternal mortality and morbidity.

Recommendation 4. The following strategies are recommended for incorporation into

preconceptional and antenatal care:

 Greater access for women and men of reproductive age to family planning services
that provide effective contraception along with counseling on the risks for adverse
birth outcomes.
 Early detection and timely management of hypertensive disease of pregnancy.
 Intermittent preventive and early treatment of malaria, especially for primiparae.
(See Chapters 3, 6, 7, and 8 for other components of this recommendation.)

Go to:

RESEARCH NEEDS
The challenge for research in the 21st century is to identify interventions that can reduce maternal,

neonatal, and fetal mortality in the developing world and thus make childbirth a safe event. This will

require particular attention to the obstetric and neonatal problems of populations with high mortality.

Promising interventions must be tested with trials that are both rigorous and practical. Successful

interventions must be monitored and adjusted for optimal effectiveness. A wide range of basic and

applied research will need to be encouraged and funded through partnerships of ministries of health,

international organizations and development agencies, nongovernmental organizations, and philanthropic

foundations.
Each country will determine its research agenda according to local priorities and the resources that can be

made available. Setting priorities for health-related research involves consideration of several factors: the

magnitude of a health problem in the local population, the likelihood of identifying a successful

intervention, the interests and capabilities of researchers, and the public perception of the importance of

the health problem. It is important to consider all factors in each setting and to balance them for the best

interests of the population in question (Brown, 1977).

The following areas of research have been identified by the committee as key to the continued

improvement of maternal and overall birth outcomes. Research priorities that target other topics appear in

the corresponding chapters.

 Studies are needed to determine the burden of disease caused by maternal and neonatal
bacterial infections in different settings. Research should include the identification of
etiologic agents and their antibiotic susceptibility. Strategies for prevention and treatment
should be informed by community-based data, including laboratory evaluations. Simple
methods to identify mothers and neonates with presumed bacterial infection (such as
algorithms based on patient history and physical findings) are also needed.
 For areas of the world with limited laboratory capacity, there is a need to develop simple,
cost-effective diagnostic tests that can be used in a field setting. Diagnostic capabilities at
health centers and referral hospitals must also be strengthened.
 Large, multicenter trials are needed to examine the cost-effectiveness of food and
micronutrient supplementation in relation to maternal and neonatal health and fetal
survival, particularly in areas where undernutrition is common. Local studies can
determine the most effective means of supplementation to improve the nutritional status
of the population, and thus of women who become pregnant.
 Studies are needed to determine whether the level of antibiotic resistance in rural
communities is significantly lower than in urban hospitals.
 Studies are needed to evaluate the targeted use of antibiotics for those women at risk for
infection during delivery who cannot be transferred to a hospital or who refuse hospital
care.
 Strategies to prevent malaria during pregnancy are needed, including ways to reduce
exposure (e.g., insecticide-impregnated bednets). Antimalarial drug resistance is
widespread. Research on the safety and efficacy of new drugs and drug combinations
should target pregnant women.
 Trials are needed to compare the effectiveness of intermittent prophylactic antimalarials
with early treatment of malaria for women having their first or second baby. These
strategies need to be tested in populations where malaria is endemic and women have
some acquired immunity and in those where malaria is not endemic and there is less
acquired immunity.
  Trials are needed to identify more effective approaches to accomplishing behavior
changes that reduce risks for adverse birth outcomes. The behavioral changes sought
include stopping smoking, avoiding pregnancy over the age of 35 years, and recognizing
the need for skilled care in pregnancy.
Go to:

CONCLUSION
The wide gap between MMRs in developed countries and developing countries, where the vast majority

of maternal deaths occur, suggests that much can be done to improve maternal survival. The two central,

interdependent elements of any strategy to improve maternal health are the provision of skilled assistance

for every delivery and access to essential obstetric care for complicated cases. Efforts to improve

maternal outcomes could be greatly strengthened through programs of antenatal and postpartum care

focused on the prevention and recognition of complications of pregnancy and childbirth. Substantial

reduction of maternal mortality and morbidity will require long-term investment in community education

and family planning and, ultimately, the empowerment of women.

Many measures that can be taken to improve maternal health—from specific medical interventions, to

research, to the strengthening of women's socioeconomic status—are likely to benefit the fetus and

neonate as well. The interventions recommended in this chapter can work in conjunction with

interventions that address neonatal and fetal mortality.

Summary of Findings: Reducing Neonatal Mortality and Morbidity in Developing

Countries
 An estimated 4 million neonates (aged up to 28 days) die each year. These deaths account
for about 40 percent of under-5 mortality and two-thirds of infant (aged up to 12 months)
mortality. Ninety-eight percent of neonatal deaths occur in developing countries.
 The true burden of neonatal mortality in developing countries is unknown because many
deaths occur in the home and are not reported. Limited epidemiological research
indicates the main causes of neonatal deaths are infections, birth asphyxia, birth injuries,
complications of preterm birth, and birth defects.
 Because complications of childbirth too frequently cause neonatal death, skilled
assistance is recommended for all deliveries along with access to the appropriate level of
neonatal care when needed.
  Preconceptional and antenatal care provide an opportunity to reduce risk factors for
neonatal mortality and morbidity. These include detection and treatment of maternal
infections; immunization of women of reproductive age against tetanus; and counseling
on risks to a healthy pregnancy and birth preparedness, emphasizing the importance of a
clean and safe delivery assisted by a skilled birth attendant.
 Clean and safe newborn care should prevent and manage neonatal infections and other
illnesses that can otherwise become life threatening. Caregivers must be able to recognize
signs of illness, and when they appear, promptly seek appropriate medical assistance.
Go to:

REFERENCES
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editor; , Lopez AD, editor. (eds). Health Dimensions of Sex and Reproduction: The
Global Burden of Sexually Transmitted Diseases, HIV, Maternal Conditions, Perinatal
Disorders, Perinatal Disorders, and Congenital Anomalies. Boston: Harvard School of
Public Health. Pp.266–296.
 AbouZahr C, Royston E. 1991. Maternal Mortality: A Global Factbook . Geneva: WHO.
 AbouZahr C, Wardlaw T, Stanton C, Hill K. 1996. Maternal mortality. World Health
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Infections. In: Murray CJL, editor; , Lopez AD, editor. (eds). Health Dimensions of Sex
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 Aggarwal R, Krawczynski K. 2000. Hepatitis E: an overview and recent advances in
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