Child birth should be a boon and blessing for a woman which she can cherish for life and should not be a bane to her life and health because mentally and physically harassed and is left with in a state of health detrimental for herself and for baby.

“Six months into her pregnancy, with no medical care to look after, no iron-FA tablets, and no TT immunization. Talking of advanced facilities is irrelevant when there is lack of proper food to meet the extra demand of pregnancy and she is toiling up and down with a heavy load on her head.” I came across such a case in my neighborhood where a construction of a house was taking place. This was the state of a lady living in a so called mega city where the health care facilities are said to be par excellence. I am a student from pre-final year of medicine and the most important part of our curriculum is Preventive and Social Medicine, which teaches us about how our government is working for the improvement of mother and child health in India. No doubt the facilities are excellent but how far they are reaching the population is our main point of concern.

An Introduction to the Problem

Improving maternal health is one of the eight Millennium Development Goals adopted by the international community at the United Nations Millennium Summit in 2000 [2], but every day, 1,500 women die from complications in pregnancy childbirth. In 2005, there were an estimated 536,000 maternal deaths worldwide. Most of these deaths occurred in developing countries, and most were avoidable [1]. It has been reported that 99% of maternal mortality occurs in developing country where 85% of the world population lives [3]. India is just another developing country which nurtures 16.7% of the world’s population [4].

Today, the Maternal Mortality Rate of India is 301 per 1,00,000 as compared to 9 per 1,00,000 of the developed countries and the Infant Mortality Rate is 54 per 1000 [1]. In spite of the growing concern about reproductive health, information on levels, trends and differentials in maternal mortality remains fragmentary in most developing countries and that certainly includes India. Policy initiatives often rest on judgments made on the basis of a small, selective cross section of the population.

Women in our country have many pregnancies on average, therefore their lifetime risk more accurately reflects the overall burden of these women. Maternal mortality in our country is high because of high complications associated with pregnancy, childbirth and postpartum period. The four major killers are severe bleeding (mostly bleeding postpartum), infections (also mostly soon after delivery), hypertensive disorders in pregnancy (eclampsia) and obstructed labor [5]. Complications after unsafe abortion are another cause of maternal deaths. Women die because of poor health at conception and a lack of adequate care needed for the healthy outcome of the pregnancy [5].

My Personal Experience as a Medical Student:

Our school, Lady Hardinge Medical College, is known for its excellence in Pediatrics and Gynecology, so we often see mothers and children seeking health care. And it is very sad to see that most of the childhood diseases and maternal morbidities can be easily prevented. It is sad to see that in India, most of the women and children suffer from infectious diseases which are almost always either an result of poor hygiene or is a sequel to superimposed infection due to deficiency disorders and malnutrition.

During our family rotations to the slums in Delhi we got a chance to closely observe the state of the community. There are many malpractices and skepticism in the society prevalent that is resulting in the poor maternal and child health status in India. Despite many pleas to people to change habits which will give rise to these problems, these issues are still prevelent. Most of the malpractices that we came across were detrimental to the health status of mother and child and as a result, the antenatal attendance was found to be very low. We carried out a study on 500 pregnant women and found that 25% were not registered and 21% of them did not seek medical attention in their last pregnancy. Further enquiry revealed that the reasons for not attending ANC clinics were tragic; 39% did not have any knowledge about them, 42% said that they could not go because of distance of the ANC clinic from their home, rest did not go because they had no time and no one to accompany them.

A study in the slums of Delhi reveals that while 91% of women recieved antenatal care, and an average of three visits were made, a large proportion of these visits were motivated by a health complication; routine monitoring accounted for no more than one-third of all first and second visits and the first contact was typically made in the fifth or sixth month of pregnancy [6].

More Deplorable Facts

Major hindrances include the fact that pregnant women often do not have knowledge of things like TT immunization, the importance of iron folic acid tablets and a balanced diet during pregnancy. Sepsis is one of the most common causes of maternal death in our society, resulting from lack of reproductive hygene.

Deaths of newborns during the first week or month of life are largely the result of inadequate or inappropriate care during pregnancy, childbirth or the first critical hours after birth. Indeed, neonatal mortality is largely dependent on maternal and pregnancy-related health. Major causes of neonatal mortality include neonatal infections (tetanus, sepsis, meningitis, pneumonia and congenital syphilis), birth asphyxia and trauma, pre-term birth and/or low birth weight. These reasons can be easily attributed to fact in our society some people prefer delivery by a Dai (most deliveries in rural areas of India are handled by the local lady who is immediately available to the pregnant lady during the perinatal period) who may not be skilled enough to handle the adversities and complications associated with pregnancy and parturition. Most of the times these Dai’s do not have knowledge of the importance of disinfection and hygiene while handling a delivery. We also observed that early onset of marriage and childbearing in India continues to have disturbing consequences for maternal health. Most of the women we came across in our society were married during their teenage years and majority were illiterate or barely had a primary education. The median age at first cohabitation with husband is 17 years among women aged 25-49 [7] and cultural pressures make it imperative for a women’s security in her marital home for her to conceive as soon as possible after marriage. Higher parity is another cause of concern that is prevalent in our community.

A recent study of pregnant women in Delhi slums reports that 45% of pregnant women were malnourished, that is their caloric intake was less than 60% of the recommended diet during pregnancy, and 80% consumed less than the recommended daily amount; 40% weighed less than 45 kg and 7% were less than 145 cm in height; two-thirds were anemic and 12%were severely anemic [6].

During our rotations we also observed that in most of the families child and mother are kept separated for the initial 40 days depriving the child of immediate nursing by mother. Neonatal health care is constrained by traditional practices that forbid women from leaving the home after they have given birth and the health system’s failure to provide home-based care in this period.

Early weaning is another practice and discarding the colostrums – the first milk – predisposes the child to various infections and deprives the child from the benefits of mother’s milk. Breast milk protects the baby from respiratory and diarrheal diseases which are the major cause of morbidity and mortality in children. In Indian setup exclusive six months of breast feeding is recommended [8].

India Fights Back

There are many national programmes functioning in India which aim at the development of Maternal and Child Health in India. Some of the programmes are Janani Suraksha Yojna under National Rural Health Mission, Reproductive Child Health Care, Integrated Management of Newborn and Childhood Illness. Under the leadership of Smt. Indira Gandhi, Integrated Child Development Services was launched which also has Nursing and Pregnant mothers as its beneficiary and children below 6 years [9]. All the programmes are being designed in a way that their main objective can be summed up as “to improve the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children.” India is currently spending US$109 per capita on the improvement of health and 4.9% of GDP on health [10]. Sadly even with so much expenditure and so many efforts by the government of India, the situation is very slow to improve.

Conclusions and What We Can Do

Pregnant women, their families, and indeed the whole community have not yet recognized the need for skilled attendance at delivery or the array of skills that a birth attendant needs. To summarize, in the communities misconceptions abound, danger signals in the pregnancy are poorly understood, provider-client interactions fail to build awareness, women’s lack of decision making authority, women’s restricted mobility, economic burden, and domestic violence are some of the major issues which we need to fight and to date no national programme has been designed to overcome these obstacles.

Actions are required to inform pregnant women and their families of danger signals and the required responses, ways of gaining appropriate care, nutrition and rest during pregnancy, and their right to recieve skilled and affordable attendance at birth. Efforts are needed to mobilize women, inform them of their rights, enable them to exert a voice in family affairs and make contingency plans for unforeseen pregnancy-related problems, and create amongst them a feeling of entitlement to health care and other services.

Shipra Goel is a third year medical student at Lady Hardinge Medical College in India
goelship(at)gmail.com

References

[1] Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva, World Health Organization, 2007 (http://www. who.int/reproductive-health/publications/maternal_mortality_2005/index.html, accessed 14 August 2008).

[2] WHO (2003), The World Health Report 2003, Shaping the future.

[3] The World Health Report – Make every mother and child count, Geneva, World Health Organization, 2005

[4] Govt. of India (2001), Census of India 2001, Provisional Population Totals, Paper-1 of 2001

[5] WHO (2005), Regional Health forum, Vol.9, No.1, 2005

[6] Bhandari, N. and S. Mayank. 1999. A study on the perceptions, prevalence and health seeking behaviour of maternal morbidities in an urban slum. Unpublished report.

[7] IIPS and ORC Macro, 2000; MOHFW, 2000

[8] Govt. of India (2004) National Guidelines on Infant and Young Child Feeding (2004) , Department of Women and Child Development, Govt. of India.

[9] Govt. of India (1978), National Plan of Action for the International Year for the children 1979, Ministry of Education and Social Welfare, New Delhi.

[10] WHO (2003), Health Situation in South East Asia, Basic Indicators 2002

Breast Cancer in India

A 35 year old female presented with bilateral advanced breast carcinoma (Stage 3) with an ulcer in the right breast, bilateral axillary lymphadenopathy and a left supraclavicular lymph node. The description adequately conveys the guarded prognosis.I worked on this case for my Surgery Practical Exam and it reinforced a thought that had been troubling me for a very long time. My patient was seeking medical help for the first time, though the lump had been present over the past two years. She had even continued to breastfeed her baby and stopped only five months ago when she developed excruciating pain. My patient is not one of those surprising exceptions who did not seek medical care on time. I have come across at least 10 such patients of breast cancer during my brief six week surgical rotation. I have tried to interview extensively all these victims, to discover the reason behind not seeking medical advice on time and ignoring a largely noticeable breast lump.

The reasons are so simple and naïve that they are distressing – the present patient did not know that hard lumps in the breasts were of any significance until she developed an ulcer a month ago. She even attributed her pain to excessive breastfeeding. Ignorance comes across as the main factor though other reasons also exist, including abusive and suppressive husbands and in-laws, and lack of knowledge among fellow female well-wishers who also are equally unaware. It is so sad to come across patients like this, especially when women in more developed countries are undergoing regular screening mammographic investigations and are well aware of breast self examination techniques.

In India, cancer of the breast is the most common cancer among women in many regions and has overtaken cervical cancer, which was the most frequent cancer a decade ago (1). It has been estimated that during the year 2001 alone, nearly 80,000 women developed breast cancer in India (2). Studies indicate that as India becomes Westernized, the incidence rate for breast cancer is increasing. A 2005 study conducted by the International Association of Cancer Research, based in Lyon, France, projected that there would be 250,000 cases of breast cancer in India by 2015, a 3% increase per year. Currently, India reports roughly 100,000 new cases annually (3).

Screening and Mortality

Screening by clinical breast examination (CBE) alone has not been demonstrated by randomized controlled trials to reduce mortality although a large trial is currently underway in Bombay by the Tata Memorial Centre(4). An IARC Working Group concluded in 2002 that there is inadequate evidence that breast screening by CBE, either alone or together with mammography, can reduce mortality from breast cancer (5). However, cancers detected by CBE tend to be diagnosed at an earlier stage than those not detected by screening, suggesting a greater potential for effectiveness in a setting where stage at diagnosis is generally poor (6). Although CBE undertaken by health workers seems to offer a cost-effective approach to reducing mortality, the sensitivity of the screening program in the real context was low with a sensitivity of only 25.6% and positive predictive value 1% (7). The UK Preventive Task Force report found that trials for breast self-examination showed no reductions in mortality but increase in benign biopsies. They concluded that no benefit has been shown for clinical breast examination or breast self-examination. On the other hand mammography screening reduces breast cancer mortality by 15% for women aged 39 to 49 years with low radiation exposure and an estimated over diagnosis of 1 to 10% (8).

While studies show that the efficacy of breast self examination is limited, it is imperative to recognize our shortcomings. India’s healthcare system is still in its developing phase, making it virtually impossible for all females to undergo regular screening mammography and general health checkups. Even so, there are still precautions that can be maintained. It is definitely possible to create awareness about the common signs and presentation of breast carcinoma, the common risk factors that may be contributory and the need for breast self examination.

Self-Examination

It is suggested that for very low resource settings in certain parts of India where population based screening, even with clinical breast examination by primary health workers is not feasible, health education combined with access to screening and treatment services, may be a simple and feasible strategy for reduction in cervix and breast cancer mortality (4). A praiseworthy practice about our hospital with a strong focus on women’s health issues, is that they not only perform a “clinical breast examination” on all women but also counsel them regarding the need for regular breast self-examination.

Reeler A et al (9) have defined a public health approach to cancers in developing countries where resources for effective cancer control are very limited and offer a framework for putting women’s cancers in developing countries on the global public health agenda. The key areas as proposed by them are: 1. Proposals for a new, integrated public health approach to women’s cancers (breast and cervical) in resource poor settings; 2. Reviews of the evidence for cost-effective screening and early detection of breast and cervical cancer; 3. Outlines of ways to make a priority of breast and cervical cancers in developing countries on the political agenda of international agencies. Implementation of such an integrated program may be the solution that we are looking for. A multilevel approach can be initiated only with active government policies and we hope that it would take shape in the near future. A number of Breast Cancer support groups and NGOs like Aastha Breast Cancer Support Group, Aarogya etc. are already doing very good work in providing medical and emotional support to affected women. Meanwhile given the current burden of breast cancer in India, it is the duty of everyone associated with medicine and anyone with a good outreach to be aware of the need of breast self-examination and to promote it whichever way they can. It is so unfortunate that even literate, educated, and well-read females are unaware of the need and method of self-examination.

We as a nation have a very long way to go. It is our duty as members of the healthcare delivery team – medical students and physicians alike – to do our part by educating and creating awareness about breast cancer and its early detection.

Gurmeen Kaur is a TLS RA and a final year medical student at Lady Hardinge Medical College, India
kaur.gurmeen(at)gmail.com

The author would like to acknowledge the assistance of Dr. Anurag Srivastava, a Breast Oncosurgeon at the All India Institute of Medical Sciences, New Delhi, India for his contributions to the paper.

References

1. Murthy NS, Agarwal UK, Chaudhry K, Saxena S. A study on time trends in incidence of breast cancer – Indian scenario. Eur J Cancer Care (Engl). 2007 Mar;16(2):185-6.

2. Murthy N.S., Juneja A., Sehgal A. & Luthra U.K. (1990) Cancer projection by the turn of century. Indian Journal of Cancer 27, 74–82.

3. Bagchi S.Breast Cancer rises in India. CMAJ. 2008 July 1; 179(1): 27.

4. Mittra I, Mishra GA, Singh S et al. A cluster randomized, controlled trial of breast and cervix cancer screening in Mumbai, India: methodology and interim results after three rounds of screening. International Journal of Cancer. 2010; 126(4): 976-984.

5. IARC Working Group on the Evaluation of Cancer-Preventive Strategies. IARC Handbooks of Cancer Prevention: Breast Cancer Screening (2002) Lyon, France: IARC Scientific Publications.

6. Duffy SW, Tabar L, Vitak B, Warwick J. Tumor size and breast cancer detection: what might be the effect of a less sensitive screening tool than mammography? Breast J (2006) 12(suppl_1):S91–S95.

7. Pisani P, Parkin DM, Ngelangel C et al. Outcome of screening by clinical examination of the breast in a trial in the Philippines. 2005; 118(1): 149-154.

8. Nelson HD, Tyne K, Naik A et al. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 2009 Nov 17;151(10):727-37, W237-42.

9. Reeler A, Qiao Y, Dare L, Li J, Zhang AL, Saba J. Women’s cancers in developing countries: from research to an integrated health systems approach. Asian Pac J Cancer Prev. 2009 Jul-Sep;10(3):519-26

Maternal deaths are a widespread health issue in developing countries. It is, though, a lesser known disabling condition that is creating an urgent need for intervention. It was in Lubango, Angola this past May that I put a face to one of the greatest health concerns for mothers. An eighteen year old girl, younger than me at the time, was facing a problem that I am unlikely ever to have.

The obstetric fistula is a chronic, disabling condition that afflicts approximately one hundred thousand new women each year, adding to the 2-3 million women already suffering (ambiguous due to unreported cases) (1,2,3). In many developing countries, expectant mothers have no access to a midwife or emergency obstetrical care to assess their ability to birth vaginally. This can result in days of obstructed labour in which the baby continuously presses against the mother’s internal tissues, restricting blood supply to the area and causing the child to asphyxiate within the womb (2). The dead tissue wastes away leaving the fistula: a hole between contiguous organs. A fistula can occur between different organs, but those seen in maternal cases are commonly the vesicovaginal (vagina and bladder) and rectovaginal (rectum and vagina) fistulas (2,3).

Women suffering from an obstetric fistula are likely to live long lives, although the trauma of the experience and the morbidity of the outcome both jeopardize the potential of their future (3). The onset of hole between the bladder or rectum and vagina leads to a continual leakage of urine and feces from the woman (3). Husbands, communities and families often ostracize these women, choosing to ignore the suffering in order not to deal with the collateral effects of the complicated birth and unpleasant symptoms (2).

The girl I met in Angola was in the hospital having a reversal of her temporary colostomy, a procedure that was done to facilitate her recovery from her fistula. The birth had been her first pregnancy and unlikely her last. A recent study looked at the birthing success of forty-nine women who had previously undergone fistulae repair (4). When a planned caesarean section was performed, forty-seven of the children survived and there was no reoccurrence of the mother’s fistula (4). Reports were also collected from hospitals that treated women who delivered vaginally or with a delayed emergency caesarean and all twenty-four women had stillbirths and reoccurrence of their obstetric fistula (4). This data emphasizes the critical need of medical care for pregnant women, something that is not easily accessible in developing countries.

There are multiple socio-economic factors that lead to the obstetric fistula (5). Malnutrition is a chronic ongoing health issue and exacerbates problems as girls have smaller statures, thus smaller pelvises (5). This leaves these girls vulnerable to the birth of a relatively large child. Women also hold a low status in many developing countries and do not have a choice in marriage or pregnancy, often being young teens in these situations (3,5). The lack of access to medical care and midwives is also crucial as it leaves no option for women carrying breech babies. The prospect of having an emergency caesarean section is often kilometres away or far too expensive for the expectant mother to consider.

Obstetric Fistula repair is ninety percent successful in less complicated cases, but still sixty percent successful in the more intricate ones (1,3). It requires surgery and at least two weeks of post-operative care to avoid excess pressure on the injured site (2). Being cured of this devastating illness seems an obvious solution, particularly to women of affluent countries where specialized obstetric care is readily available and often covered by insurance. The reality in poor countries, where this condition typically occurs, is that a USD$300-450 surgery and hospital stay are inconceivable (1,3). Many girls also lack the knowledge of available treatment options and have resigned themselves to suffer (3).

The Angolan girl avoided eye contact with me while she was in the consulting room. She exuded a feeling of shame and embarrassment, not uncommon to these women. Many women who suffer a fistula are scorned and told this is a curse; a punishment for something they did (3). Left untreated, they are divorced and expelled from their household duties (3). What little these women had to start with is taken away. The isolation leads to psychological consequences, exacerbating the pain of losing a child and their perpetual incontinence.

The Fistula Foundation and the Campaign to End Fistula run by the United Nations Population Fund are two organizations spearheading the fight against this illness. They are not only trying to raise money, but also educating the developed world of this largely neglected condition. Education is an important tool in relieving the suffering. Understanding that there is a treatment and that they have the right to a safe pregnancy, as well as promoting the knowledge that this is not their fault, can diminish the depression many individuals face (5).

The hospital I visited in Angola, the Evangelical Medical Centre of Lubango (CEML) (6) was providing the obstetric fistula repair surgery for free. It is the work of institutions like this that are actively promoting the well-being of mothers in the developing world and trying to reverse the associated stigma. The obstetric fistula is ubiquitous in many developing countries and it is time we acknowledge the magnitude of its damage and put resources into implementing better medical access for pregnant women.

Jill Murray is a third year global health student at the University of Toronto in Canada
jillm203(at)gmail.com

References

(1) The Fistula Foundation. What is Fistula? [document on the Internet]. The Fistula Foundation; 2009. [cited 2009 September 20]. Available from http://www.fistulafoundation.org/aboutfistula/.

(2) Wall, LL. Obstetric vesicovaginal fistula as an international public-health problem. The Lancet. 2006;368(9542):1201-1209

(3) Campaign to End Fistula. About Fistula [document on the Internet]. United Nationals Population Fund; 2006 [cited 2009 September 20]. Available from http://www.endfistula.org/index.htm.

(4) Browning, A. Pregnancy following obstetric fistula repair, the management of delivery. An International Journal of Obstetrics and Gynaecology. 2009;116(9):1265-1267

Reshma Patil and Avinash Patil write on the substantial health and economic consequences of poor maternal nutrition.

The United Nations’ (UN) Millennium Development Goals aim to halve the proportion of people suffering from hunger between 1990 and 2015. (1) Currently, 11% of the total global disease burden has been attributed to undernutrition. (2) While the sequelae of child malnutrition have been well studied, the longitudinal effects of fetal growth restriction and perinatal nutrient deficiencies are gaining increasing attention. (2) Intrauterine growth restriction followed by rapid weight gain in childhood is associated with increased risk of cardiovascular and metabolic disease. (3,4) Additionally, the UN has reported that the effects of chronic malnutrition are long lasting, often leading to recurrent illnesses, decreased educational attainment, and a lower level of skills and lifetime earnings. (1) (more…)

Muhammad Umair Mushtaq, a fourth year MBBS student from Allama Iqbal Medical College in Pakistan, writes on newborn care in Pakistan, including the challenges of the current health care system and recommendations for possible solutions.

About 4 million newborns under 4 weeks old perish each year, accounting for 37% of all under-five deaths.[1]  Nearly 75 % die in the first week and 40% in the first 24 hours after birth. Newborns in developing countries are eight times more likely to die than newborns in industrialized countries.[2]  Ninety-nine percent of all newborn deaths occur in developing countries.[3]

Pakistan has a population of about 160 million and a per capita GDP of 736 US$, with only 2.4% of GDP being spent on health.[4]  The current newborn health status of Pakistan is characterized by a high incidence of low birth-weight babies and neonatal mortality. About 0.3 million newborns die each year (Figure 3) with a neonatal mortality rate of 57 per 1000 live births (Figure 2) . About 19% of all newborns have low-birth weight and only 16% of all babies are exclusively breastfed.[5]  Neonatal diseases are a major cause of mortality, with 55.7% deaths among children under-5 years.[4]  Pakistan is a signatory to the Millennium Development Goal targets of reducing maternal and infant mortality by 66-75% by the year 2015.[6]  

To achieve the Millennium Development Goals related to newborn health, many international organizations are working in collaboration with national governments to improve mother and newborn health, such as Partnership for Maternal, Newborn and Child Health (PMNCH), United Nations Development Fund, United Nations Children’s Fund (UNICEF), and World Health Organization (WHO).

In most instances, neonatal deaths result from poor maternal care during pregnancy, poor hygiene during delivery, unskilled management of complications, harmful traditional practices, inadequate newborn care, and lack of access to emergency care. 15% of newborn infants weigh less than 2,500 g, the proportion ranging from 6% in developed countries to more than 30% in least developed parts of the world, the main cause being preterm birth.[2]  In Pakistan, intrapartum or early postnatal deaths are common and the perinatal mortality rate is 59 per 1,000 total births.[2]  This is mostly due to maternal infections or nutrient deficiency and an absence of appropriate obstetric and neonatal care. In developing countries, asphyxia causes around 7 deaths per 1,000 births, whereas in developed countries this proportion is less than 1 death per 1,000 births. 26% of newborn deaths occur as a result of severe infections like sepsis and pneumonia.[2]  Exact figures are not known for Pakistan, but the situation is not much better. Globally, neonatal tetanus causes 7% neonatal deaths. Although neonatal tetanus has been eliminated from many countries by maternal tetanus toxoid (TT) immunization, there are over 50 countries where, in some districts, the proportion of cases of neonatal tetanus is 1 per 1k000 births.[2]  In Pakistan, about 80% of newborns are prevented from neonatal tetanus by TT immunization, but cases are frequent in remote and rural areas.[7]

Table 1: Estimates of stillbirths, early neonatal, perinatal and neonatal mortality rates and numbers, 2000

(more…)

There is much more to maternal mortality in Afghanistan than the appalling statistics as Mahri Zohra Haider explains

Statistics on maternal mortality in Afghanistan are among the worst in the world, second only to Sierra Leone. There are 1,800 maternal deaths per 100,000 live births (or one maternal death for every 55 births) and Afghan women have a one in eight lifetime risk of maternal death. (1) The average birth rate is 6.75 children per woman and every pregnancy is associated with a risk of death that is 600 times greater than that of a woman who is pregnant in North America. (2) Although the problem of maternal deaths in Afghanistan is clear in the numbers, the solutions lie in the details beyond the numbers. However, all too often the majority of effort is spent on dissecting the problem, with merely an afterthought to what can actually be done. One study designed to verify the above statistics concluded that “deaths could be averted if complications were prevented through improvement of general health status” and if “complications that occurred were treated to reduce their severity.” (3) These recommendations are vague and fail to draw attention to the specific challenges of addressing maternal mortality in Afghanistan. (more…)

 Islean Kinghorn discusses the public health implications of this emotive issue

WHO defines unsafe abortion as ‘the termination of an unintended pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both.’ (1) According to their statistics 19.7 million women a year undergo unsafe abortions, contributing to 13% of maternal deaths worldwide. (2) If we are to achieve Millennium Development Goal 5 of reducing maternal mortality ratio by ¾ we must address the taboo of unsafe abortion.

The consequences of unsafe abortion on a woman’s health are many. Some such as haemorrhage or infection lead to mortality, while others, including pelvic inflammatory disease, can leave women with chronic pain and an increased risk of obstetric complications or infertility.(3) Such morbidity, easily avoided with safe practice, places a staggering strain on health systems, diverting scant resources from other essential programmes. It has been estimated that each year 5.2 million women are hospitalised worldwide due to complications following unsafe abortion. (4) The global cost to health systems could be as high as US$ 1.08 billion annually. (5) However it is not only the direct but indirect costs, through loss of productivity and the vulnerable position of motherless children, that burden society. (more…)

Rachel Pope uses the story of a woman she interviewed in Tanzania to highlight the complex issues involved in the lack of appropriately trained health workers

Pili (her name has been changed to protect her privacy ) is a 27 year old woman from the Kara tribe. (1) She only made it to grade three in school, and was married at age 18. She was also 18 the first time she gave birth, but unfortunately for Pili, she does not have any children to this day due to complications in both of her labours that resulted in an obstetric fistula. (An obstetric fistula is the result of prolonged and obstructed labor. In cases where the fetus cannot pass through the birth canal safely, the constant pressure of the fetal skull in the birth canal reduces blood supply to the tissues, causing the tissues to disintegrate. Fistulas – or holes – develop, resulting in constant leaking of urine and/or feces through the vagina.) (more…)