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Risking Death to Give Life
For anyone who has been through the experience, or seen someone else go through it, there is no doubt that childbirth is a life-changing event. Unfortunately, as wonderful and joyful experience as it is for many, it can also be a difficult period, bringing with it new problems as well as the potential for suffering. In the most extreme cases the mother, or the baby, or both, may die; these deaths are only the tip of the iceberg. Many health problems are laid down in the critical hours of childbirth – both for mother and for child. Many more continue to unfold in the days and weeks after the birth. The suffering related to childbirth adds up to a significant portion of the world’s overall tally of ill-health and death ( 1 ). Most of the deaths and disabilities attributable to childbirth are avoidable, because the medical solutions are well known. The challenge that remains is therefore not technological, but strategic and organizational.
Maternal mortality is currently estimated at 529 000 deaths per year ( 2 ), a global ratio of 400 maternal deaths per 100 000 live births. Where nothing is done to avert maternal death, "natural" mortality is around 1000–1500 per 100 000 births, an estimate based on historical studies and data from contemporary religious groups who do not intervene in childbirth ( 3 ). If women were still experiencing "natural" maternal mortality rates today – if health services were discontinued, for example – then the maternal death toll would be four times its current size, totalling over two million maternal deaths per year worldwide. The truth is that three quarters of these deaths are currently avoided throughout the world: nearly all the "natural" maternal mortality in developed countries, but only two thirds in the South-East Asia and Eastern Mediterranean Regions and only one third in African countries.
There are immense variations in death rates in different parts of the world. Maternal deaths are even more inequitably spread than newborn or child deaths. A tiny 1% of maternal deaths occur in the developed world. Maternal mortality ratios range from 830 per 100 000 births in African countries to 24 per 100 000 births in European countries. Of the 20 countries with the highest maternal mortality ratios, 19 are in sub-Saharan Africa. Regional rates mask very large disparities between countries. Regions with low overall mortality rates, such as the European Region, contain countries with high rates. Within one single country there can be striking differences between subgroups of the population. Rural populations suffer higher mortality than urban dwellers, rates can vary widely by ethnicity or by wealth status, and remote areas bear a heavy burden of deaths.
Maternal deaths are deaths from pregnancy-related complications occurring throughout pregnancy, labour, childbirth and in the postpartum period (up to the 42nd day after the birth). Such deaths often occur suddenly and unpredictably. Between 11% and 17% of maternal deaths happen during childbirth itself and between 50% and 71% in the postpartum period ( 4 – 8 ). The fact that a high level of risk is concentrated during childbirth itself, and that many postpartum deaths are also a result of what happened during birth, focuses attention on the hours and sometimes days that are spent in labour and giving birth, the critical hours when a joyful event can suddenly turn into an unforeseen crisis. The postpartum period – despite its heavy toll of deaths – is often neglected ( 4 , 9 ). Within this period, the first week is the most prone to risk. About 45% of postpartum maternal deaths occur during the first 24 hours, and more than two thirds during the first week ( 4 ). The global toll of postpartum maternal deaths is accompanied by the great and often overlooked number of early newborn deaths and stillbirths.
Maternal deaths result from a wide range of indirect and direct causes. Maternal deaths due to indirect causes represent 20% of the global total. They are caused by diseases (pre-existing or concurrent) that are not complications of pregnancy, but complicate pregnancy or are aggravated by it. These include malaria, anaemia, HIV/AIDS and cardiovascular disease. Their role in maternal mortality varies from country to country, according to the epidemiological context and the health system’s effectiveness in responding ( 10 ).
The lion’s share of maternal deaths is attributable to direct causes. Direct maternal deaths follow complications of pregnancy and childbirth, or are caused by any interventions, omissions, incorrect treatment or events that result from these complications, including complications from (unsafe) abortion. The four other major direct causes are haemorrhage, infection, eclampsia and obstructed labour (see Figure 4.1). The levels of maternal mortality depend on whether these complications are dealt with adequately and in a timely manner ( 10 ).
The most common cause of maternal death is severe bleeding, a major cause of death in both developing and developed countries ( 11 , 12 ). Postpartum bleeding can kill even a healthy woman within two hours, if unattended. It is the quickest of maternal killers. An injection of oxytocin given immediately after childbirth is very effective in reducing the risk of bleeding. In some cases a fairly simple – but urgent – intervention such as manual removal of the placenta may solve the problem. Other women may need a surgical intervention or a blood transfusion, both of which require hospitalization with appropriate staff, equipment and supplies. The proportion needing hospital care depends, to some extent, on the quality of the first-level care provided to women; for example, active management of the third stage of labour reduces postpartum bleeding. The proportion that dies depends on whether appropriate care is provided rapidly. The situation with regard to postpartum bleeding could improve if the promising potentialities of the drug misoprostil are realized. Misoprostil is less effective than oxytocin, but it is cheaper, easier to store safely and does not require an injection. Therefore it remains attractive where women do not have access to professional care at birth. If further research can demonstrate its effectiveness in the many cases where oxytocin is not an option, misoprostil could save many lives and reduce the number of women who suffer anaemia as a result of a postpartum haemorrhage – currently 1.6 million every year.
The second most frequent direct cause of death is sepsis, responsible for most late postpartum deaths. During the 19th century puerperal sepsis took on epidemic proportions, particularly in lying-in hospitals. The introduction of aseptic techniques brought a spectacular reduction of its importance in the developed world ( 13 ). However, sepsis is still a significant threat in many developing countries. One out of 20 women giving birth develops an infection, which needs prompt treatment so as not to become fatal or leave sequelae ( 14 ). Puerperal sepsis leads to tubal occlusion and infertility in 450 000 women per year.
Hypertensive disorders of pregnancy (pre-eclampsia and eclampsia) – which are associated with high blood pressure and convulsions – are the cause of 12% of maternal deaths. They usually occur during pregnancy but also during childbirth ( 15 ). Mild pre-eclampsia can be monitored in pregnancy, but the transition to severe pre-eclampsia or eclampsia requires care in a hospital environment.
Obstructed labour – owing to disproportion between the fetal head and the mother’s pelvis, or to malposition or malpresentation of the fetus during labour – varies in incidence: as low as 1% in some populations but up to 20% in others. It accounts for around 8% of maternal deaths globally, while the baby may be stillborn, suffer asphyxia and brain damage or die soon after birth. Skilled practitioners, such as midwives, can deal with many of these problems before labour becomes obstructed, or recognize slow progress and refer for caesarean section or instrumental delivery. Disabilities associated with obstructed labour that is dealt with late or inadequately can be very significant both for mother and child ( 12 ). For the mother the most distressing potential long-term conditions following obstructed labour are obstetric fistulae (see Box 4.1).
Of the 136 million women who give birth each year, some 20 million experience pregnancy-related illness after birth ( 30 ). The list of morbidities is very diverse, ranging from fever to psychosis, and the range of care responses needed is correspondingly varied. For those women who have almost died in childbirth, recovery from organ failure, uterine rupture, fistulas and other severe complications can be long, painful and leave lasting sequelae. Other, non-life-threatening illnesses are frequent as well: in India, for example, 23% of women report health problems in the first months after delivery ( 31 ). Some of these problems are temporary but others become chronic. They include urinary incontinence, uterine prolapse, pain following poor repair of episiotomy and perineal tears, nutritional deficiencies, depression and puerperal psychosis, and mastitis ( 32 ) (see Box 4.2). Even less is known about these morbidities than about maternal deaths. They are difficult to quantify, owing to problems with definitions and inadequate records ( 33 ). More and more reliable information on the whole range of morbidities would be an important step towards better planning of services and improved care around childbirth.
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