DELAYS IN SAFE MOTHERHOOD

DELAYS IN SAFE MOTHERHOOD MEANS DEATH

Many women die due to delay at several levels while seeking medical help. The community and health workers must work hand in hand to prevent this delay and addressing this problem will reduce maternal death and promote safe motherhood.

Some causes of delay in acquiring medical care

Delay in decision making.

✔ Lack of information on health services available
✔ Communication barrier in language or bad roads and physical barriers like lakes or mountains
✔ Lack of resources e.g. no money or husbands is away and transport cannot be got to transport mother to the hospital
✔ Inappropriate care e.g. mother taken to TBAs first
✔ Lack of decision making by the mother since she is waiting for the husband to come back to give her permission and money.

Delay in reaching the health facility

✔ Distance may delay the mother so that by the time she reaches the hospital is too late
✔ Transport may not be available to take mother quickly to hospital
✔ Road may be bad and impossible taking a longer time to reach hospital
✔ Cost of transport may be too high for the mother

Delay in receiving adequate care

✔ Unskilled staffs who lack knowledge on what to do for the mothers and dealing with high risk pregnancy
✔ Drugs may not be available in the health units, this includes blood for transfusion, antibiotics, analgesics, etc
✔ Lack of equipment e.g. sterile supplies which may delay cesarean section or syringes which may delay giving an oxytocic drugs
✔ Few varieties of services offered at the health facilities.

Factors that affect delay to seek medical care

Family – mother may be single or young and does not know whether she is pregnant or fears to go to health unit – mothers may wait for a decision to be made by the husband who may be away – mother -in- law may delay as she tries to manage giving herbs for contraction
Husband – she may take time to decide or may be away looking for money
Education level – if lowly educated, mother may not think of seeking the advice
Socio-economic status – poverty may prevent quick action
Natural barriers – like rivers, likes, mountains and floods
Security; wars and insurgencies

Maternal Mortality

This is the death of a woman/mother while pregnant or within 42 days of the termination of pregnancy irrespective of the duration and the sites of pregnancy from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

Maternal mortality rate

This is the ratio of the total number of maternal deaths occurring in a period of time (usually a year) to the total number of live births occurring in the same period expressed as a percentage (or per 1,000 or 100,000).

Incidence

Worldwide, every year approximately 8 million women suffer from pregnancy related complications. Over half a million of them die as a result. The problem of maternal mortality and morbidity are greatest (99%) for the poor women in the developing countries. One woman of 11 may die of pregnancy related complications in developing countries compared to one in 5000 in developed countries. It is further estimated that for 1 maternal death at least 16 more suffer from severe morbidities.

The maternal mortality rate in Uganda has been declining over the years, from 506/100,000 in 2004 to 435/100,000 in 2011. However, this is one of the highest in the world and demands for more concerted efforts towards its reactions. The new report released by the World health organization (WHO) has shown a remarkable decrease in maternal mortality by 44% worldwide due to fully implemented millennium development goals. However, there is not much difference in the reduction in the developing countries like Uganda.

Factors contributing to the high maternal mortality in Uganda

There is no single factor that can be counted on as responsible for the high maternal mortality in Uganda. It is rather an interplay of factors. Any approach therefore, aimed at effectively addressing maternal mortality has to pay a close look at all those factors. The easily identifiable ones in Uganda include the following:

Poverty

Several women are engaged in productive work at home and do not have means of earnings. Such women cannot afford to meet even simple costs like transport in case any emergencies develop. Poverty also means that the woman will not be able to afford basic human needs like food which will predispose the woman to further complications during pregnancy and/or labour. They are also likely to be less privileged in the fields of nutrition, housing, education and antenatal care.

Gender issue

In Uganda, men are decision makers on all matters in the home including health care seeking. This means that the woman may have to wait for the man to grant her permission in order to seek medical care. Some women are even prevented from attending antenatal care by their husbands. This predisposes the mother to developing complications in the absence of a trained health worker who can offer help.

Inadequate and inaccessible health services

There are very few health facilities equipped to handle and manage conditions associated with pregnancy and delivery. Despite government policy of bringing services close to the people, some women need to travel long distances in order to access a health facility. This usually keeps those who feel unwell away as they may not be in position to walk or have the money for transport.

Limited health workers

The number of trained health workers in Uganda is still very low compared with the skyrocketing population. This has resulted in long queues observed daily at the various rural and urban health facilities as clients wait to be attended to. Unfortunately others go back without attention. This discourages many and at the end, women prefer to be

attended to by the village traditional healer or herbalist who may not have the necessary skills to manage incase complications develop.

Poor attitudes of health workers towards mothers.

On many occasions, health workers have been reported of being rude, arrogant and unfriendly while attending pregnant women and those in labour. This scares such women away and finally ends up in the hands of untrained people for help. Health workers need to develop better attitudes and make the caring environment friendly so as to motivate mothers to seek health services from them.

Early marriages

For a long, the girl child has been seen as a source of wealth for the family. Girls are forced into marriages at a tender age for the family to acquire cattle and money. These girls get pregnant before their bones and bodies are fully developed which predisposes them to various complications during pregnancy and/or labour.

Illiteracy

Women, over the years, have comprised the highest number of those who cannot read and write. This means that they cannot effectively influence policy on matters that affect them like reproductive health. As such, they surrender all rights of decision making to the men

including the number of children to have and sometimes the age of marriage. Education keeps girls in school until they are old enough to marry and have children. It also empowers them to stand out for their rights and freedom.

Beliefs, customs and taboos(harmful traditional practices)

Some traditional customs, beliefs and taboos predispose women to developing complications during pregnancy or labour. Denying women some nutritious foods like chicken, eggs etc. predispose them to malnutrition which in turn has a negative bearing to reproductive life. Practices like female genital mutilation predispose the woman to extensive perineal tears that may lead to excessive hemorrhage during child birth and yet the use of some traditional herbs (Cytoxic herbs) may predispose to uterine rupture. Some communities perceive women who deliver from health units as not strong being enough. This is dangerous as it predisposes any woman to unnecessary complications during labour.

Poor transport and communication infrastructures

Statistically, seventy five percent (75%) of the Ugandan population lives in rural areas and yet most of the health facilities are located in urban centers. The road network linking up these areas are very poor in most of the areas which delay transfer of women in case complications develop during pregnancy or labour. This is more common in geographically impassible areas like mountainous parts of Kigezi, areas encircled by water bodies.

High child mortality

Uganda‘s child mortality is still high though it has been declining over the years. Parents are filled with uncertainties as to how many of their children will make it to adulthood. As such, they prefer to produce many for a few to survive. For example, in post war Northern Uganda, many people claim that they have lost their relatives more than expected in the war and so the need to produce more children is valued currently.

Desire for more children

Many people perceive children as a source of prestige in the community. A family with many children was always looked at as being very strong and secure and as a result, many people desire to have many children and yet more children mean more deliveries and moiré risk for maternal mortality.

Sex preferences in children

Some women may keep on giving birth in an attempt to get a child of their preferred sex. Parents tend to rate children of different children sex differently as a result may prefer a particular sex. This is risky to the mother who carries and delivers the pregnancy and also unhealthy to the father and children due to inadequate care that will be provided and received.

High fertility rate

Uganda has a very high fertility rate estimated at about 7 children per woman per reproductive life span. It is one of the highest in the world. This implies that women are exposed to the risks many times.

Underutilization of the existing services
Inadequate drug supplies and other medical related equipment is most often interrelated and are responsible for an increased number of avoidable deaths. Poor referral systems for handling emergency
Poor attitudes by the health workers
Noninvolvement of the husbands
Lack of awareness/ignorance
Disrespect for human rights
Gender stereotypes and inequalities

Delays that can lead to maternal mortality

In most instances, women who die in childbirth experienced at least one of the following delays:

1. Delays at the individual woman‘s levels

– Inability to make decision on life threatening health conditions in time for appropriate response
– Late recognition that there is a problem,
– Fear of the hospital or of the costs that will be incurred there,

Delay at the level of the family and community levels in decision making to assist the woman to more/husband‘s issues/ in laws‘ issues.
Delay at the level of accessing services. Usually transport is a major problem and or lack of resources. Many villages has very limited transportation options and poor roads.
Delay in the health units to institute the necessary interventions.

– Inadequate skills and poor staffing
– Failure to make appropriate decision
– Lack of drug supplies etc.

Note: Not only mothers die, babies too die. 4000,000 newborn deaths occur globally yet almost all are due to preventable conditions.

Causes of maternal mortality

There are several causes of maternal mortality broadly grouped into direct and indirect causes. In Uganda 506 per 100,000 women die of pregnancy and birth related and recent data shows that 16 women die every day during giving birth related complications in Uganda.

A direct death is one resulting from obstetric complications of pregnancy, delivery or from interventions, omissions or incorrect treatment or a chain of events resulting from the above.

An indirect death is one resulting from a previously existing diseases (present before) or developed during pregnancy and was not due to obstetric causes but aggravated by the physiological effects of pregnancy.

Direct Causes of Maternal Mortality

i) Sepsis

This is a common cause of maternal mortality. All women get infections when membranes rupture early, delivered in dirty environments like gardens or following operative procedures where the aseptic technique was compromised. All women should be given prophylactic antibiotics following cesarean section. Women who had prolonged labour or early rupture of membranes should be given antibiotics. If such a woman develops fever, she should be carefully assessed, admitted and appropriate treatment instituted as soon as possible.

ii) Hemorrhage

This is a serious condition especially in women with underlying anemia or bleeding disorders. It may present as APH due to placental retention, uterine inertia etc. women should be encouraged and given micronutrient supplements during pregnancy, screened for anemia and always book some units of blood for mothers in labour.

iii) Early pregnancy deaths

This is death resulting from ectopic pregnancies and abortions. This is one of the major causes of maternal mortality in Uganda. Criminal abortions account for the highest number of deaths in this category.

iv) Hypertensive conditions

Severe pre-eclampsia and eclampsia are common causes of maternal mortality. If any mother develops any of these complications should be managed effectively. Magnesium sulphate is the drug of choice. Ensure proper fluid management. Always identify any risk factors of developing pre-eclampsia in a mother during antenatal care and manage them promptly and effectively whenever possible.

v) Others

– Thrombosis and thrombo-embolism
– Genital trauma

Indirect causes of maternal mortality

i) Cardiovascular diseases

– Pulmonary hypertension
– Endocarditis

ii) HIV/AIDs

iii) Malnutrition

iv) Diabetes
v) Thyroid diseases
vi) Anemia

Predisposing factors to maternal mortality and morbidity

∙ Early pregnancy (less than 20 years old);
∙ Uncontrolled fertility;
∙ Low socioeconomic status of women;
∙ Poverty and lack of empowerment of women;
∙ Lack of access to quality services;
∙ Inadequate referral systems;
∙ Lack of support from spouses.

Prevention of maternal mortality

Eighty percent (80%) of these deaths can be prevented through actions that are effective and available in developing country‘s settings. This is a coordinated long term effort within the families, countries and health systems, national legislation and policy.

Primary prevention

Girl child education

Education keeps girls at school until they are old enough to marry and have children. This means that they get fewer pregnancies and produce fewer babies. Educated women will also have more chances of getting employed and have money to look after themselves better. Education also empowers them to stand out for their rights and freedom.

Proper nutrition of the girl child

Malnutrition during childhood and puberty has been closely related to the inadequate development of the pelvis (contracted). This usually predisposes the woman to developing obstetric complications like Cephalopelvic disproportion (CPD). Parents should be educated that girl children need more to eat as much as boys and adolescent girls should be encouraged to eat adequate food for proper body development and functioning.

Family planning

Maternal mortality is common in women who get pregnant while too young (below 20 years of age). Most cases of criminal abortion that turns out with complications are as a result of unwanted pregnancies. Family planning provides an absolute answer to all these questions by enabling the mother (couple) to have children by chop ice and not by chance.

Quality antenatal care

All pregnant women should be encouraged to have timely attendance of at least 4 quality antenatal visits, where the woman is fully assessed for presence of any risk factors that may predispose her to developing complications. Once any risk factor has been identified, it should be managed effectively and appropriately during antenatal care.

Immunization

All women in the reproductive age should be immunized against tetanus, HepB. This is because; such women are at higher risk of developing the infections during any time in the reproductive cycle.

Provision of information, education and communication about maternal mortality. Individuals and families should be given adequate information about the causes of maternal mortality and how they can be prevented. It is important that such messages spell out the roles of each individual in preventing maternal mortality. Individuals should be empowered to take action and stop thinking that the sole role of government is to protect and care for their lives.

Secondary prevention

A skilled attendant should be present at every birth. Functional referral systems is very essential here
Emergency obstetric care services are to be provided and made accessible to the people
Transport and communication networks need to be improved to gain access to all health facilities. Transport means like ambulances should be made available and accessible.
Health facilities should be equipped with adequate equipment, operating theaters which should be functional, blood storage facilities in case of any emergency, equipment in good working conditions and drugs. The government should always ensure a steady supply of essential drugs.
Adequate referral systems for complications should be instituted. Clients should be in position to get assistance from a higher level in the shortest time possible. Some clients decline referrals because they are not sure of obtaining any better help at the next level. In most cases, such clients either refuse and stay at the referring health units or go home and wait for whatever may happen next.
Proper evaluation and reporting of maternal deaths and timely intervention taken
Decentralization of services to make them available to all women
Barriers to the access to health care facilities should be removed; policies should increase women‘s decision making power as regards to their own health and reproduction.
Recruitment of skilled staffs to balance of the workload
Improving the standard and quality of care by organizing refresher courses for the health care personnel.

Tertiary prevention

This involves the control and management of complications that may arise
Emergency obstetric care services should be provided.

Maternal Morbidity

Although considerable attention has been given to maternal mortality, very little concern has been expressed for maternal morbidity. It is estimated that for one maternal death at least 15 more suffer from severe morbidities. As such about an optimistic 5-7 million suffer a severe impaired quality of life as a result of short term or long term disability.

Definitions

Obstetric morbidity originates from any cause related to pregnancy or its management any time during antepartum, intrapartum and postpartum period, usually up to 42 days ( weeks) after confinement.

Parameters of Maternal Morbidity

✔ Fever more than 38 degree centigrade
✔ Blood pressure greater than 140/90mmHg
✔ Recurrent vaginal bleeding
✔ Hb less than 10.5g/dl irrespective of gestational age
✔ Asymptomatic bacteriuria of pregnancy

Classifications

i) Direct obstetric morbidity

– Temporary
– Permanent

ii) Indirect obstetric morbidity

Direct

∙ Temporary (mild)

– APH, PPH, eclampsia, obstructed labour
– Rupture uterus
– Sepsis
– Ectopic pregnancy
– Molar pregnancy etc.

∙ Permanent (chronic)

– Vesico-vaginal fistula and rectovaginal fistula
– Dyspareunia
– Prolaps
– Secondary infertility
– Obstetric palsy

Indirect

These conditions are only expressions of aggravated previous existing diseases like malaria, hepatitis, tuberculosis, anemia etc. by changes in the various systems during pregnancy.

Perinatal Mortality

This is defined as deaths among fetuses weighing 1000 g or more at birth (greater than 28 weeks gestation) that die before or during delivery or within the first 7 days of delivery. The Perinatal mortality rate is expressed in terms of such deaths per 1000 total births. The Perinatal mortality rate closely reflects both the standards of medical care and effectiveness of public and social health measures. According to WHO, the limit of viability is brought to a fetus weighing 500g (22 weeks).

Incidence

∙ Worldwide nearly 4 million newborns die within the first week of life and another 3 million are born dead.
∙ Perinatal deaths could be reduced by at least 50% worldwide if key interventions are applied for the newborn.
∙ Perinatal mortality is less than 10 per 1000 total births in the developed countries while in the developing it is much higher.
∙ The major health problem in the developing world arise from the synergistic effects of malnutrition, infections and unregulated fertility combined with lack of adequate obstetric care
∙ Majority of feotal deaths (70-90%) occur before the onset of labour. The important causes.

Predisposing factors to perinatal mortality

Many factors influence the perinatal mortality in Uganda and theses are briefly discussed below;

Maternal factors

a) Epidemiology

– Age over 35 years
– Teenage pregnancies
– Multiparity
– Low socio economic condition(poverty)
– Poor maternal nutritional status

Note. All the above adversely affect the pregnancy outcome

b) Medical disorders

– Anemia (Hb less than 8g/dl)
– Hypertensive disorders
– Syphilis
– Diabetic mellitus
– Prematurity
– Congenital malformation (baby)
– Malaria
– Other infections

c) Obstetric complications

– Antepartum hemorrhage (APH) particularly abruptio placentae is
responsible for about 10% of perinatal death due to severe hypoxia
– Pre-eclampsia, eclampsia is associated with high perinatal loss either due to placental insufficiency of prematurity
– Rhesus Iso-immunization
– Cervical incompetence which may lead to premature effacement and
dilatation of cervix between 24-36 weeks

d) Complications of Labour

– Dystocia from disproportion, mal-presentation and abnormal uterine action
– Premature rupture of membranes (PROM) may result in hypoxia, amnionitis and birth injuries contributing to perinatal death

Feto-placental factors (causes)

– Multiple pregnancy, most often leads to preterm delivery and usual complications
– Congenital malformation and chromosomal abnormalities are responsible for 15% of perinatal death
– Intrauterine growth restriction and low birth weight babies

Unexplained causes

About 20% of stillbirths have no obvious fetal, placental, maternal or obstetric causes.

4. Other causes/risk factors refer to maternal mortality

Causes of perinatal mortality

Infection

– Sepsis
– Meningitis
– Pneumonia
– Neonatal tetanus, congenital

Birth asphyxia and trauma

Hypothermia

Prematurity and/ low birth weight
Congenital malformation

Control and prevention of perinatal mortality

As every mother has a right to conclude her pregnancy safely, so also the baby has a right to be born alive, safe and healthy. As such improvement of obstetric services will not minimize perinatal death appreciably therefore simultaneously demographic and social changes help in the reduction of perinatal mortality rate significantly. The following measures are helpful in reducing perinatal mortality.

Pre pregnancy health care and counseling
Genetic counseling in high risk cases and prenatal diagnosis to detect genetic, chromosomal or structural abnormalities are essential
Regular antenatal care with advice regarding health, diet and rest
Detection and early management of medical disorders in pregnancy such as anemia, diabetes, hypertension
Screening of high risk clients where mandatory hospital delivery is instituted like those from poor socioeconomic status, high parity, extreme of age etc.
Careful monitoring and management of Labour to detect hypoxia, early evidence of traumatic vaginal delivery etc.
Skilled birth attendance to minimize sepsis
Provision of neonatal referral services especially to look after the preterm babies
Health education of the mothers about the care of a new born such as early exclusive breastfeeding and prevention of hypothermia
Educating the community to utilize family planning services and also to utilize the available maternity and child health care services
Increased resource allocation towards maternal and child health services
Regular review of perinatal death cases and ensuring effective supervision, monitoring and evaluation to realize the missing gaps
Improving on social infrastructures like health care, transport and communication network
Continuous decentralization of maternal and child health care services

Preconception Care

The outcome of pregnancy depends so much on the factors that operate during the period of growth and development of the mother from childhood. Some of the factors which influence proper growth and development of the mother are;

– type of birth and circumstances surrounding her birth
– her birth weight
– breast feeding and nutrition
– childhood infections
– formal education
– sexual and reproductive health education and services utilization
– Socio-cultural practices

Therefore it is important that the girl child is given adequate care during this period of development.

Pre-conception refers to the care of women and men during their reproductive years, which are the years they can have a child. It focuses on taking steps now to protect the health of a baby they might have sometimes in the future.

However all women and men can benefit from preconception care, whether or not they plan to have a baby one day. This is because part of preconception health is about people getting and staying healthy overall, throughout their lives. In addition, no one expects an unplanned pregnancy. But it happens often.

Preconception care is the medical care a woman or man receives from trained medical professionals that focus on the parts of health that have been shown to increase the chance of having a healthy baby.

Preconception health is important for every woman, not just those planning pregnancy. It means taking every woman, not just those choosing healthy habits. It means living well, being healthy and feeling good about your life. Preconception care is about making plans for the future and taking the steps to get there.

Preconception care is important for men too. It means choosing to get and stay as healthy as possible and helping others to do the same as well. As a partner it means encouraging and supporting the health of your partner. As a father, it means protecting your children.

Healthy babies

Preconception care is a precious gift to babies. For babies it means their parents took steps to get healthy before pregnancy. Such babies are less likely to be born early (preterm) or have a low birth weight; they are likely to be born without birth defects or other disturbing conditions. Preconception care gives babies the best gift of all the best chance for a healthy start in life.

Healthy families

Ensuring preconception health is a great way to create a healthy family. The health of a family relies on the health of the people in the family. Taking care of your health now will help to ensure a better quality of life for yourself and your family in the coming year.

Objective

Assess clients‘ readiness for pregnancy by ensuring adequate mental, physical and socio economic readiness.
Prevent, treat and manage medical conditions that affect pregnancy and the newborn. 3. Prepare for pregnancy and childbirth
Promote safer and responsible sexual behaviors
Promote delay of age at first pregnancy
Prevention of HIV and sexually transmitted disease

Services offered during Preconception Care

Education and information on:

– Sexuality
– Growth and development of the coming child
– Pregnancy and child birth
– Responsible parenthood
– Family planning
– STI/HIV
– Malaria prevention
– Personal hygiene
– Nutrition
– Use of drug during pregnancy (drugs of abuse and medicine )
– Previous health intervention – repair of Vesico-vaginal fistula, ruptured uterus, treatment for infertility etc.
– Diabetes mellitus

Screening for and managing conditions which may complicate pregnancy, childbirth and health of the mother and child thereafter e.g.

– HIV
– Syphilis
– Sickle cell diseases – Heart disease
– Hypertension

Provision of services

– Congenital abnormalities – Aneamia
– Diabetes Mellitus
– Mental illness
– Folic acid supplementation 3 months for woman before pregnancy
– Immunization
– Deworming for women
– Management of STI/STDS and other identified diseases
– Provision of long other insecticide treated nets
– Routine screening for reproductive health cancers
– Family planning
– VCT for HIV

Support channels.

– Identify and locate the organization that will support the groups and work with them.
– Appropriate counseling of individuals and couples about their pregnancy needs
– Establishing the pre pregnancy health status/profile for the purpose of follow up.
– Identify special group women such as, disabilities, adolescence and HIV infection
– Develop appropriate intervention to address the needs of the different special groups
– Mobilize and sensitize the community to be supportive to the needs of the special groups.

Responsible motherhood and fatherhood
Contraception and family planning information and service.

Where Can Preconception Care be done.

∙ Health units
∙ Community based group.

Ways to reach out to special groups.

∙ Health education in the community
∙ Mass media
∙ Church groups
∙ Appropriate ITC materials
∙ Opinion leaders.