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Anemia is a major cause of maternal mortality in India. In 1990, 19% of the maternal deaths were related to anemia. It is also a contributory factor to maternal deaths caused by hemorrhage, septicemia, and eclampsia. Anemia caused by lack of iron is the commonest nutritional deficiency in the world. According to recent reports, a significant number of children and women in the western world are also iron deficient. An adult man needs a daily amount of 1.1 mg of iron, compared with twice as much by a woman even when she is not pregnant. The total iron needed during pregnancy is about 1000 mg. The daily requirements for iron, as well as folate, are 6 times greater for a woman in the last trimester of pregnancy than for a nonpregnant woman. In healthy, well-nourished women with adequate iron stores, about half the total requirement of iron during pregnancy may come from maternal reserves. If the diet is not supplemented with extra iron, a woman will become progressively depleted of iron during pregnancy, and anemia will result. Lack of iron directly affects the immune system; it diminishes the number of T-cells and the production of antibodies. The World Health Organization (WHO) defined 3 stages of iron-deficiency: decreased storage of iron without any other detectable abnormalities; iron stores are exhausted, but anemia has not occurred yet; and overt iron deficiency when there is a decrease in the concentration of circulating hemoglobin. The end result of iron deficiency is nutritional anemia. Most Indian women are anemic with a hemoglobin level of 7-10.5 gm% (the norm is 11.5-14.0 gm%). Iron supplementation, calcium supplements, and a high-protein diet should be given these women during pregnancy. They should also be made aware about proper birth spacing, especially in rural areas, under existing government education programs.
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PMID:Anaemia -- a major cause of maternal death. 1217 89

A study of 165 maternal deaths at the University of Benin Teaching Hospital, Benin City over a 13-year period (from April 1, 1973 to December 31, 1985) is presented. All patients' case files were recovered from the central records library and each case file was carefully analyzed. With a total delivery of 29,324, the maternal mortality rate, inclusive of death from abortion, was 563/100,000 deliveries. There was a general increase in maternal mortality rate with age and this became alarming from 35 years. There was an equally high mortality rate among teenagers, mainly accounted for by illegally induced abortion. Indeed, abortion accounted for 72% of teenage mortality. A statistically significant association between maternal deaths and parity (p, 0.001) was observed. The most important causes of death were hemorrhage with a total of 26 out of 42 deaths, sepsis, and abortion. Other important causes were hypertensive disorders such as eclampsia, liver and respiratory disease, anemia, trophoblastic diseases, caesarean sections, and acute renal failure. Additional causes of maternal deaths include tetanus, sickle-cell disease, anesthetic death, drug reactions, pulmonary embolism, acute pyogenic meningitis, typhoid disease, urinary bladder tumor, acute lymphoblastic leukemia, and carcinoma of the breast thyroid. Factors identified with these deaths included such health services factors as deficient medical treatment of obstetric complications, lack of adequate personnel at primary and secondary health care levels, lack of access to maternal health services, and consequently, lack of prenatal care. Extreme reproductive age, grandmultiparity, and unwanted pregnancies, especially among teenagers, also contributed to maternal deaths. Overhaul of the maternal health care services at national level to include organization of such programs as provision of adequate blood transfusion facilities, prompt treatment of infections, early referrals of patients at risk to secondary and tertiary health centers, intensified family planning programs, and liberalization of abortion laws are recommended in order to reduce the unacceptably high maternal mortality.
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PMID:Maternal mortality at the University of Benin Teaching Hospital Benin City, Nigeria. 1217 71

The paper presents the maternal mortality rates in St. Mary's Hospital Urua Akpan from the period of 1979-1985 excluding (1981 Author on leave). 70% of maternal deaths were among unbooked local Annang women who lived within a radius of 15-20 miles from the hospital. They had been attended to by traditional birth attendant (TBAs) and referred too late. The maternal rate decreased from 10/1000 in 1979 to 4/1000 in 1985. The main causes of maternal death during this period include ruptured uterus, septicemia, hepatitis, hemorrhage, eclampsia, and hypertension/nephritis. A community survey (190 interviewed women) revealed that up to 50% of women still prefer to deliver at home and are attended to by TBAs. A training program for TBAs in the Local Government Area (LGA) was started in June 1983. Each course lasted 3 months in which basic instruction in hygiene, simple antenatal care, labor and its complications, and care of mother and child was given. Since starting the program, the TBAs have referred 320 patients with medical pregnancies, vacuum, and symphysiotomy. From 1983-1986, there were 38 perinatal deaths and 2 maternal deaths among the TBAs referrals. Since 1983, the maternal death rate and morbidity have fallen especially among women from the LGA; maternal mortality declined 50% among these women which account for only 30% of the total hospital births/year. Furthermore, 16,000 children have been vaccinated. The beneficial aspects of TBA training include observing the principles of hygiene, early referral of patients to hospital, encouraging village children to come for vaccinations and generally using their influence in the cultural, ritual and religious life of traditional society to become good health educators.
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PMID:Training traditional birth attendants reduces maternal mortality and morbidity. 1217 76

The objectives of this study are to determine the trend of maternal mortality at the University of Ilorin Teaching Hospital, to identify the causes of death, and to identify ways of minimizing the frequency of preventable deaths. Analysis of 75 cases of maternal deaths seen over 3 1/2 years (January 1983-June 1986) was conducted. During this period, there were 26,905 births, giving a maternal mortality rate of 279/100,000. 84% of the deaths were due to direct causes while the remaining 16% were classified under the indirect and pregnancy related categories. The main direct causes of death include hemorrhage (35.6%), septicemia (24.7%), and anemia (13.7%). Other direct obstetric causes include eclampsia, anesthetic death, hemoglobinopathy, and ruptured uterus. The most important indirect causes were native drug intoxication (6.8%), fulminant hepatitis (5.5%), and pulmonary embolism (2.7%). The maternal mortality was highest in the age ranges 25-29 years (31.5%). Median age and parity were 27 years and 4.5 respectively. While the maternal mortality rate of 2.8/1000 is an improvement over the previous years' (1972-1982) record of 4.3/1000, it is still unacceptable. The majority of these deaths could have been prevented if delivery had occurred in a well equipped hospital where blood transfusion and surgical facilities are available, if sterile manipulations for pregnant women had been employed, if appropriate antenatal care was available, and if specialist anesthetist services were accessible. Recommendations to reduce the maternal mortality rate include improved education and training of traditional birth attendants, improved immunization of women against tetanus, and increased community involvement through education. Furthermore, policy makers must set new priorities such as encouraging greater investment in improving clinics and hospital facilities, improving access to contraception, increasing awareness of the magnitude of the problem and encouraging community leadership and action.
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PMID:Maternal mortality at Ilorin, Nigeria. 1217 82

Examination of 34,114 case notes from booked hospital patients during 1979-1984 at the University of Nigeria Teaching Hospital in Enugu revealed 2106 emergency cesarean sections (6.1%) and a maternal mortality rate of 0.8% in these patients. The major cause of death was septicemia followed by liver failure, acute renal failure, hemorrhage, eclampsia, anesthetic accidents, and pulmonary embolism. Antenatal care accounts for lower maternal death rates in booked patients receiving cesarean sections compared to unbooked patients; mortality rate in booked patients was 8.5/1000 and 45/1000 in unbooked patients. Requiring all antenatal patients to give a pint of blood before booking assured available blood during emergency operations. Deaths from anesthesia could be prevented by employing only qualified, experienced specialists. Enforced aseptic techniques during surgery could lower post operative sepsis which in turn could reduce maternal deaths. Emergency cesarean sections were found to be safe. This observation is dependent on patient acceptance of appropriate antenatal care, requiring a donation of blood on booking, enforcing rigid aspetic surgical techniques, providing qualified anesthetists, and promoting good antenatal care.
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PMID:Maternal mortality from emergency caesarean section in booked hospital patients at the University of Nigeria Teaching Hospital Enugu. 1217 84

Analysis of hospital records from January 1983 to December 1985 at the Komfo Anokye Teaching Hospital in Kumasi, Ghana revealed a maternal mortality rate of 12.5/1000 births. During this period, 27,592 births and 342 maternal deaths occurred. The primary cause of death was hemorrhage(32.14%). Other leading causes of maternal deaths include hepatic failure (19.53%),postpartum hemorrhage (18.75%), eclampsia (11.01%), sepsis (10.71%), ruptured uterus (8.33%), and anemia (4.76%). Comparison of deaths with clinic attendants and non-clinic attendants revealed 43.68% more deaths with non-clinic attendants. 29.02% of the maternal deaths were among primipara and 31.09% among grandmultipara. Furthermore, 41.9% of the deaths were among women 24 years. A health profile of the Ashanti-Akim district indicated 14.8% of the population are females in the reproductive range; 47.1% live in areas having a population of 500; 55.1% reside within a 8 km radius of a health center; a 1:19,500 physician/population ratio; 45% greater home births in rural areas and 9% in urban areas; traditional birth attendants (TBAs) delivered 63% of all births. Adequate data gathering and maternal death registration are current problems. Through education, TBAs could collect available information on maternal mortality, make regular visits to the areas, and bring awareness to the population of the need for medical care. TBAs could provide a valuable contribution to the health care systems in improving maternal-child health and assist in reducing maternal mortality rates.
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PMID:Maternal mortality in Ghana: is there a place for traditional birth attendants (TBAs) as reporters of maternal mortality-related data? 1217 85

A survey was carried out in urban and rural areas of the district of Anantapur, Andhra Pradesh state, India, between July 1, 1984-June 30, 1985 by a team of 6 interviewers and 1 supervisor to identify investigate, and study the causative factors/characteristics of the causes of maternal deaths. They visited each of the 15 hospitals in the district collecting information about maternal deaths that occurred in the reproductive age range of 15-49 years. 22 health centers and 50% of subcenters were also visited, registers were examined, and staff and families were also interviewed. The hospitals and centers served 569,500 people. During the 1st phase in the rural area all main village centers, 181 village subcenters, and 1192 other villages in the district with a total population of 1,090,640 were covered. During the 2nd phase all towns in the urban zones, 10 primary centers, 65 subcenters, and 135 others were visited. The maternal mortality rate was 7.9/1000 live births, well above the national average. 36% of female mortality occurred in women in reproductive age, but fewer than 1/2 of these deaths were registered and only 1/3 figured in center and subcenter records. In rural areas maternal mortality was 8.3/1000, ahead of the urban rate of 5.4/1000. 63% of 284 deaths detailed were related to live births, 14% to stillbirths, 10% to abortions, and 13% to obstructed labor. 19% of total maternal deaths occurred before birth, 12% during labor, and 69% after delivery. Among clinical causes of death sepsis accounted for 36%, hemorrhage for 12%, eclampsia for 9%, retention of placenta for 7%, and infectious hepatitis for 10%. 80% of these deaths could have been avoided by timely antenatal care, treatment of previous complaints, and medical attention and hospitalization at the right time.
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PMID:[New data on maternal mortality in India]. 1217 49

The hospital of Attat in central Ethiopia serves 300,000 people. In 1987 there were 777 deliveries in the hospital, maternal mortality was 21.2/1000 live births, and the rate of stillbirths was 212/1000 total births. In 1976 a residence or tokul with 15 beds was inaugurated for pregnant women with obstetrical problems to mitigate obstetrical emergencies because of the difficulty of transportation to the hospital. Average stay was 15 days with prenatal care by a hospital nurse visiting the tokul once a day. There were 15 villages around the hospital with 15,000 inhabitants, and a 5-member development committee met with a public health matters. In 1987 a total of 151 pregnant women were admitted, most with a history of obstetrical problems. 34 had caesareans (19 of 25 with previous caesareans), 7 had assisted delivery, and 30 had spontaneous delivery. Only 7 of 15 with previous uterine rupture gave birth via the abdominal route, the others delivered vaginally. There were 635 deliveries of women who entered the hospital directly. Only 142 out of 151 women who stayed at the tokul gave birth in the hospital: 9 of them went home. Many of the direct hospital cases had severe problems: 45 suffered uterine rupture and 23 had craniotomy of the stillborn fetus. 88 (25%) of 348 abnormal deliveries required caesarean section, while there were 44 (72%) caesareans in 61 abnormal deliveries in the tokul group. 13 women died in the direct admission group vs. none in the tokul cases. The maternal mortality rate was 21.2/1000 live births. Rupture of the uterus caused 5 deaths, eclampsia 3, hepatic coma 2, grave sepsis 2, and placenta previa 1. There were 161 fetal deaths in 635 pregnancies of the direct referral group. The stillborn rate was 253.5 vs. 28.2/1000 births in the tokul group.
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PMID:[Residences for pregnant women reduce the risk of obstetrical catastrophies]. 1217 50

The results of a survey conducted by Family Health International of 55,000 deliveries in 23 health facilities in 10 countries of sub-Saharan Africa indicate the importance of prenatal care to pregnacy outcome. Infant of mothers who had received prental care were significantly more likely to survive the early neonatal period than infants whose mothers received no prenatal care. Moreover, chances of neonatal survival rose with increases in the number of prenatal visits. Prenatal care also reduced the number of complication of delivery, especially among women with 4 or more previous births. On the basis of these findings, it is suggested that the objective should be to provide at least some prenatal care to all pregnant women in this area and to build in a system for identifying and providing more intensive care to women at highest risk. Total coverage of the sub-Sahran region requires a team approach. The team should consist of physicians, nurses, midwives, community health assistants, and traditional birth attendants. Given the shortage of physicians and nurses in this region, the need to cooperate with and train traditional birth attendants is particularly important. Their training should include the identification of risk factors and danger signs, including anemia, sepsis, hemorrhage, obstructed labor, and eclampsia. Community outreach programs need to be designed to encourage women to use prenatal services, and health education programs (covering topics such as oral rehydration therapy, immunization, and breast feeding) should be organized on a continuous basis. The integration of family planning and primary health care services is also crucial.
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PMID:Maternity, infant care needs remain unmet in sub-Saharan Africa. 1226 50

Nearly 99% of maternal deaths in the world each year occur in developing countries. New efforts have recently been undertaken to combat maternal mortality through research and action. The medical causes of such deaths are coming to be better understood, but the social mechanisms remain poorly grasped. Maternal mortality rates in developing countries are difficult to interpret because they tend to exclude all deaths not occurring in health care facilities. The countries of Europe and North America have an average maternal mortality rate of 30/100,000 live births, representing about 6000 deaths each year. The developing countries of Asia, Africa, and Latin America have rates of 270-640/100,000, representing some 492,000 deaths annually. For a true comparison of the risks of maternal mortality in different countries, the risk itself and the average number of children per woman must both be considered. A Nigerian woman has 375 times greater risk of maternal death than a Swedish woman, but since she has about 4 times more children, her lifetime risk of maternal death is over 1500 times greater than that of the Swedish woman. The principal medical causes of maternal death are known: hemorrhages due to placenta previa or retroplacental hematoma, mechanical dystocias responsible for uterine rupture, toxemia with eclampsia, septicemia, and malaria. The exact weight of abortion in maternal mortality is not known but is probably large. The possible measures for improving such rates are of 3 types: control of fertility to avoid early, late, or closely spaced pregnancies; effective medical surveillance of the pregnancy to reduce the risk of malaria, toxemia, and hemorrhage, and delivery in an obstetrical facility, especially for high-risk pregnancies. Differential access to high quality health care explains much of the difference between mortality rates in urban and rural, wealthy and impoverished areas of the same country. The social determinants of high maternal mortality rates include political, geographic, and economic mechanisms of exclusion which affect the vast majority of the population in developing countries. Political power is concentrated in the hands of relatively small groups whose decisions about such expenditures as health care are usually more favorable to the privileged. A consequence of the very unequal regional development in most Third World countries is that health, educational, and most other resources are concentrated in large cities and perhaps 1 or 2 strategic regions, leaving most of the population underserved. The low social position of women leaves them doubly vulnerable. The social factors adding to risks of maternal mortality should be considered in programs of prevention if the causes and not just the consequences are to be addressed.
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PMID:[Maternal death: unequal risks]. 1228 79


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