Global Maternal and Neonatal Health

Estimates of Global Maternal and Neonatal Mortality

It is estimated that almost 300,000 women worldwide die each year from the complications of pregnancy and childbirth, with 99% of these deaths occurring in low-resource countries. Estimates from 2017 by the World Health Organization (WHO) and other partners show that two-thirds of all maternal deaths occur in sub-Saharan Africa alone and about one-fifth of all maternal deaths occur in Southern Asia. For every woman who dies, around 20 women have serious ill health and lifelong disability as a result of these same complications.

In 2015, the United Nations (UN) adopted 17 Sustainable Development Goals (SDGs), with 169 targets, building on the UN Millennium Development Goals. All UN Member states have agreed to work towards achieving these SDGs by 2030. SDGs 3 and 5 are of particular relevance, although some of the other SDG targets, if achieved, will also positively impact maternal and newborn health.

SDG 3 – ‘ensure healthy lives and promote well-being for all ages’ – includes specific targets for maternal and neonatal health:

Reduce the global maternal mortality ratio to less than 70 per 100,000 live births (target 3.1).
Reduce neonatal mortality to at least as low as 12 per 1000 live births (target 3.2).
Ensure universal access to sexual and reproductive health care services, including family planning, information and education and integration of reproductive health into national strategies and programmes (target 3.7).

SDG 5 – ‘achieve gender equality and empower all women and girls’ – also includes several relevant targets, which will impact maternal and newborn outcomes:

End all forms of discrimination against all women and girls (target 5.1).
Eliminate all forms of violence against women and girls (target 5.2).
Eliminate all harmful practices, such as child and forced marriage and female genital mutilation (target 5.3).
Ensure universal access to sexual and reproductive health and reproductive rights (target 5.6).

Although the latest estimates of maternal deaths published in 2017 suggest a decline in maternal mortality since 1990, there is lack of progress in a number of countries, especially in sub-Saharan Africa and Southeast Asia ( Table 39.1 ).

Table 39.1

Estimates of Maternal Mortality Ratio, Annual Number of Maternal Deaths, and Lifetime Risk of Maternal Death by WHO Region, 2017

Region	Maternal Mortality Ratio (Deaths per 100,000 Live Births)	Annual Number of Maternal Deaths	Lifetime Risk of Maternal Death
Sub-Saharan Africa	542	196,000	1:37
Northern Africa and Western Asia	84	9,700	1:380
Central and Southern Asia	151	58,000	1:260
Eastern and Southeast Asia	69	21,000	1:790
Latin America and the Caribbean	73	7,700	1:640
Australia and New Zealand	7	26	1:7800
Oceania (excluding Australia and New Zealand)	129	380	1:210
Europe	10	740	1:6500
North America	18	760	1:3100
World	211	295,000	1:190

WHO, World Health Organization.

At least 70% of all maternal deaths globally result from five direct complications that are well understood and can be readily treated: haemorrhage, sepsis, hypertensive disease, complications of obstructed labour and unsafe abortion. This is in contrast to causes of death in countries with low maternal mortality rates, where maternal deaths are more likely to be due to indirect causes ( Figs 39.1 and 39.2 ). In addition to this high number of maternal deaths, an estimated 2.4 million neonatal deaths and 1.9 million stillbirths occur each year. Neonatal deaths account for nearly half of all deaths of children under 5 years of age.

Fig. 39.1, Causes of maternal death in Africa .

Fig. 39.2, Causes of maternal death in high-resource countries .

The health and survival of the neonate is closely related to that of the mother. The majority of deaths in the first month of life could also be prevented if interventions were in place to ensure good maternal health ( Fig. 39.3 ). Many birth injuries and birth asphyxia, and most neonatal tetanus, could be prevented with skilled professional care at the time of the birth as well as in the antenatal and postnatal periods. Similarly, many cases of sepsis in the neonate are directly linked to the health of the mother and/or the care she received during childbirth. It is estimated that almost half of all stillbirths in under-resourced countries occur during labour and birth.

Fig. 39.3, Causes of neonatal mortality .

Obstetric Causes of Maternal Mortality

The five main causes of direct obstetric maternal mortality are discussed here.

Haemorrhage

Many maternal deaths in resource-poor areas are caused by or associated with haemorrhage. This may be because of antepartum bleeding (e.g., abruption of the placenta), bleeding during birth (e.g., with a ruptured uterus or placenta praevia) or postpartum (e.g., from an atonic uterus or retained placenta).

The risk of dying from haemorrhage is higher if women are already anaemic in pregnancy (Hb <11.0 g/dL). Oxytocics are very effective in preventing postpartum haemorrhage (active management of the third stage), as well as in treating uterine atony, but oxytocics may not be routinely used and/or available. Manual removal of a retained placenta can be carried out by trained midwives and doctors using simple general anaesthesia (e.g., with intramuscular (IM) ketamine). The ability to give intravenous (IV) fluids, safe blood transfusion and anaesthesia is extremely important when pregnancy or birth is complicated by haemorrhage. It is estimated that non-availability of blood for transfusion accounts for about a quarter of deaths associated with haemorrhage.

Obstructed labour

Most cases of maternal death associated with obstructed labour are attributable to rupture of the uterus ( Figs 39.4A , B ). Persistent malposition, for example, transverse lie, is also a cause of rupture of the uterus if unrecognised and allowed to progress ( Fig. 39.5 ). The correct use of a partogram has been shown to be very helpful in making a diagnosis of cephalopelvic disproportion (CPD) or simple failure to progress. The WHO Labour Care Guide (2020) has superseded the basic partogram as an improved tool for labour monitoring ( Fig. 39.6 ), as its adjusted ‘alert values’ (to prompt a response) reflect the range of acceptable rates of progress in labour, prompting timely diagnosis of failure to progress or CPD but reducing the risk of over-intervention.

Fig. 39.5, Obstructed labour from a transverse lie, with an arm, leg and cord prolapse .

Fig. 39.6, WHO Labour Care Guide. The ‘alert’ column presents thresholds for abnormal observations that require further action, intervention or referral by the health care provider. (From World Health Organization. WHO Labour Care Guide: User’s Manual . Geneva: World Health Organization; 2020. https://www.who.int/publications/i/item/9789240017566 .)

In many cases of obstructed labour, women are referred to a health care facility late. The presenting part may be deeply impacted in the pelvis and a vaginal examination may identify oedema and overlapping of the fetal skull bones. The mother will be dehydrated, exhausted, in severe pain from a tonically contracted uterus, or pyrexial as a result of infection and/or sepsis. If the uterus has ruptured, the fetal heartbeat is usually absent and the fetal parts may be easily palpated abdominally. In addition, the woman may be in shock as a result of bleeding or sepsis. Bleeding during labour should always be a cause for alarm if CPD is suspected.

A woman with CPD in labour may also have a Bandl ring. This is a visible constriction seen in the abdominal contour, which is a warning sign of impending rupture of the uterus. If the presenting part has been impacted in the pelvis for many hours, pressure necrosis of the genital tract as it is compressed between the baby’s head and the bony pelvis may lead to obstetric fistulae. Vesicovaginal fistulae are the most common, but rectovaginal and ureterovaginal fistulae also occur. Such fistulae may also occur after difficult obstetric abdominal surgery. Women who suffer from fistulae often have no living child, become outcasts from their society, and may live in poverty. Very many women with fistulae are unable to access suitable care.

In order to try to prevent fistulae, or to encourage small fistulae to close spontaneously, it is important that all women who have survived prolonged or obstructed labour (with or without a caesarean section (CS)) should be treated initially by continuous bladder drainage with an indwelling urinary catheter and, preferably, with antibiotics to minimise the risk of urinary tract infection. Spontaneous closure can occur within 6 to 8 weeks with such conservative management, but most fistulae do not heal spontaneously and require specialised surgical management. Such surgery requires considerable expertise and specialists (obstetrician–gynaecologists and urologists) will need to seek additional training to be able to offer a good surgical repair. Equally important is the provision of good nursing care, physiotherapy and steps towards rehabilitation and reintegration into society for women who have suffered fistulae.

Sepsis

Sepsis following prolonged membrane rupture or retained products of conception (incomplete miscarriage or unsafe abortion) may lead to overwhelming septic shock, multisystem failure and death. Early recognition and prompt commencement of antibiotic treatment is important. If there are retained products of conception, manual vacuum aspiration (MVA) of retained products of conception can be lifesaving ( Fig. 39.7 ). This has, in many countries, replaced the traditional technique of dilatation and curettage (D&C), which requires general or regional anaesthesia. With good technique, MVA can be performed in early pregnancy under local anaesthesia.

Unrecognised rupture of the membranes during pregnancy risks ascending infection and can lead to chorioamnionitis, premature birth and major systemic sepsis if not recognised and treated during the antenatal period. Prophylactic antibiotics must always be given after prolonged membrane rupture and at the time of a CS.

Untreated sexually transmitted infections (STIs) are common during pregnancy in low-resource settings and may contribute to sepsis. Similarly, underlying impairment of the overall immune response – for example, with human immunodeficiency virus (HIV) infection – carries an increased risk of opportunistic infections and makes it more difficult to treat sepsis when this occurs.

Hypertensive diseases of pregnancy

Eclampsia, especially if a seizure is prolonged, can lead directly to maternal death. As pre-eclampsia and eclampsia are multi-organ diseases, the exact cause of such a death can often be difficult to ascertain. Cerebral haemorrhage is probably the most common cause of death, but renal or hepatic failure, respiratory failure, coagulopathy or HELLP ( h aemolysis, e levated l iver enzymes and l ow p latelets) syndrome may also contribute.

Recognition of pre-eclampsia by measurement of blood pressure and testing of urine for protein should be available for all women during pregnancy and after birth. Magnesium sulphate reduces the incidence of seizures in women with severe pre-eclampsia and is the preferred treatment drug for an eclamptic seizure (see Chapter 28). For a woman with severe pre-eclampsia and eclampsia, delivery is needed urgently. This obviously requires the means to expedite birth by induction of labour or by CS. Adequate control of blood pressure with medication is important to prevent cerebral accidents (both haemorrhagic and ischaemic). Close monitoring in a designated high-dependency area of the ward of such sick women is very useful in preventing and treating further complications, which may include pulmonary oedema.

Unsafe abortion

As abortion is illegal in many countries in Africa, Latin America, the Middle East and Asia, attempts at abortion are often carried out by unskilled practitioners outside the existing medical care system, These are known as ‘unsafe abortions’. Unsafe abortions may lead directly to maternal death through uterine perforation, sepsis and haemorrhage. Maternal deaths from abortion are more frequently seen with the non-availability of safe abortion services ( Fig. 39.8 ).

The occurrence of unsafe abortion is strongly linked to the non-availability of contraception. Many women do not have access to a full range of contraception. In some instances, they may not be able to use contraception without permission from their husbands and/or family-in-law. Young girls in particular often encounter significant barriers to accessing contraceptives if they are not married or in a recognised and approved relationship ( Fig. 39.9 ).

Fig. 39.9, Many women have few fertility choices .

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here