Delays in Safe Motherhood, Maternal Mortality & Preconception Care

The 3-Delay Model: Causes of Delay in Acquiring Medical Care

In most instances, women who die in childbirth have experienced at least one of the following three delays. Understanding these specific barriers is critical for any midwife.

1. Delay in Decision Making (Seeking Care)

This delay occurs at the level of the individual woman, her family, and the community. It involves the inability or hesitation to make a timely decision regarding life-threatening health conditions.

• Lack of Information: Ignorance or lack of knowledge regarding the health services available, or late recognition that a physiological problem (danger sign) actually exists.
• Communication & Physical Barriers: Communication barriers in language, or extreme physical barriers such as mountains, lakes, or impassable bad roads that discourage the family from attempting the journey.
• Lack of Resources: The family has absolutely no money, or the husband is away, and immediate transport cannot be secured to take the mother to the hospital.
• Inappropriate Care: The mother is taken to an untrained Traditional Birth Attendant (TBA) first, wasting critical hours before hospital referral is considered.
• Lack of Decision-Making Autonomy: The mother cannot make the decision to leave the house independently; she is forced to wait for her husband to return to give her explicit permission and money.
• Fear: Deep-seated fear of the hospital environment, fear of the costs that will be incurred there, or fear of poor treatment by medical staff.

2. Delay in Reaching the Health Facility

Once the decision is made, the next hurdle is physically accessing the services.

• Vast Distances: The sheer geographical distance may delay the mother so much that by the time she reaches the hospital, it is too late to reverse the complication (e.g., severe hemorrhage).
• Lack of Transport: A vehicle or ambulance may simply not be available in the village to take the mother quickly to the hospital.
• Poor Road Networks: Roads may be completely bad, muddy, or impassable, taking a drastically longer time to reach the hospital.
• Exorbitant Transport Costs: The cost of hiring private transport in an emergency is often far too high for the mother or her family to afford.

3. Delay in Receiving Adequate Care at the Facility

The woman has arrived, but institutional failures cause fatal delays in intervention.

• Unskilled Staff: Health workers who lack the necessary obstetric knowledge, skills, or confidence to deal with high-risk pregnancies and emergencies.
• Lack of Essential Drugs: Life-saving drugs may not be available in the health units. This includes a lack of blood for transfusion, IV antibiotics, anticonvulsants, and analgesics.
• Lack of Equipment: Absence of sterile supplies which may delay a vital Cesarean section, or a simple lack of syringes which delays the administration of life-saving oxytocic drugs.
• Limited Service Varieties: Few varieties of comprehensive emergency obstetric services offered at the specific health facility, requiring a secondary referral.

Specific Factors That Affect the Delay to Seek Medical Care

• Family Dynamics: The mother may be single or young and does not know whether she is pregnant, or she fears going to the health unit. Mothers-in-law may cause delays by attempting to manage the labour using traditional herbs for contractions.
• The Husband: He may take too much time to decide, or he may be far away looking for money.
• Education Level: If lowly educated, the mother may not even think of seeking professional medical advice.
• Socio-Economic Status: Severe poverty prevents quick action, as all medical and transport steps require funding.
• Natural Barriers: Geographical obstacles like rivers, lakes, mountains, and seasonal floods.
• Security: Outbreaks of wars, insurgencies, or civil unrest making travel impossible.

Maternal Mortality

Definition: Maternal mortality is the death of a woman/mother while pregnant or within 42 days of the termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management (but not from accidental or incidental causes).

Maternal Mortality Rate (Ratio): 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 per 100,000.

Global and Local 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 is greatest (99%) for poor women in developing countries. One woman out of 11 may die of pregnancy-related complications in developing countries, compared to 1 in 5,000 in developed countries.
• For every 1 maternal death, at least 16 more women suffer from severe morbidities.
• Note on Newborns: Not only mothers die; babies die too. 4,000,000 newborn deaths occur globally, yet almost all are due to preventable conditions.
• Ugandan Context: The maternal mortality rate in Uganda has been declining over the years, from 506/100,000 in 2004 to 435/100,000 in 2011. Recent data shows that 16 women die every day during giving birth in Uganda. While the WHO reports a 44% worldwide decrease due to MDGs, developing countries like Uganda have not seen as drastic a difference.

Factors Contributing to High Maternal Mortality in Uganda

There is no single factor responsible for the high maternal mortality in Uganda. It is an interplay of the following factors:

• Poverty: Several women engage in unpaid productive work at home. They cannot afford simple transport costs during emergencies or basic human needs like nutritious food, predisposing them to complications and denying them adequate housing and ANC.
• Gender Issues & Inequality: Men are the sole decision-makers. Women must wait for a man's permission to seek care. Some are entirely prevented from attending ANC by their husbands.
• Inadequate & Inaccessible Health Services: Very few facilities are fully equipped. Despite government policies, women still travel vast distances to access care, keeping unwell women away.
• Limited Health Workers: A skyrocketing population against a low number of trained workers results in massive daily queues. Discouraged mothers often leave and prefer traditional village healers who lack emergency skills.
• Poor Attitudes of Health Workers: Health workers are frequently reported as rude, arrogant, and unfriendly. This scares women away, forcing them into the hands of untrained people.
• Early Marriages: The girl child is viewed as a source of family wealth (cattle/money). Forced into marriage at a tender age before their bones and bodies are fully developed, they are highly predisposed to severe labour complications.
• Illiteracy: High illiteracy means women cannot influence policy or stand up for their rights. Education empowers girls, keeps them in school until they are old enough to marry, and reduces pregnancy rates.
• Harmful Beliefs, Customs, and Taboos: Denying pregnant women nutritious foods (like chicken/eggs) causes malnutrition. Female Genital Mutilation (FGM) causes extensive hemorrhage. Use of traditional cytotoxic herbs causes uterine ruptures. Communities often stigmatize hospital deliveries as a sign of "weakness."
• Poor Transport & Communication Infrastructure: 75% of Ugandans live in rural areas with poor road networks, delaying emergency transfers (especially in mountainous Kigezi or areas encircled by water).
• High Child Mortality: Uncertain if their children will survive to adulthood, parents produce many children so a few survive (e.g., in post-war Northern Uganda).
• Desire for More Children & Sex Preferences: Children are a source of prestige. Families desire many children, or keep delivering in an attempt to get a specific sex, heavily multiplying the mother's lifetime risk of death.
• High Fertility Rate: Uganda has one of the highest fertility rates globally (approx. 7 children per woman). This exposes women to obstetric risks many times over.
• Underutilization of Existing Services: Ignorance and lack of awareness lead to poor usage of the facilities that do exist.
• Systemic Failures: Inadequate drug supplies, poor referral systems, disrespect for human rights, and deep gender stereotypes.

Causes of Maternal Mortality

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

An Indirect death is one resulting from a previously existing disease (or a disease developed during pregnancy) that was not due to obstetric causes but was aggravated by the physiological effects of pregnancy.

Direct Causes of Maternal Mortality

• i) Sepsis: A very common cause. Results from early rupture of membranes, dirty delivery environments (like gardens), or compromised aseptic techniques during C-sections. Action: Prophylactic antibiotics must be given after C-sections or prolonged labour.
• ii) Hemorrhage: Extremely serious, especially in women with underlying anemia. Presents as Antepartum Hemorrhage (APH), placental retention, or uterine inertia. Action: Micronutrient supplements during pregnancy, anemia screening, and booking blood for labour.
• iii) Early Pregnancy Deaths: Resulting from ectopic pregnancies and abortions. Criminal/unsafe abortions account for the highest number of deaths in this category in Uganda.
• iv) Hypertensive Conditions: Severe pre-eclampsia and eclampsia. Action: Magnesium sulphate is the drug of choice. Ensure proper fluid management and early identification during ANC.
• v) Others: Thrombosis, thrombo-embolism, and genital trauma (e.g., uterine rupture).

Indirect Causes of Maternal Mortality

• i) Cardiovascular diseases: Pulmonary hypertension and Endocarditis.
• ii) HIV/AIDS
• iii) Malnutrition
• iv) Diabetes
• v) Thyroid diseases
• vi) Severe Anemia

Predisposing Factors

Early pregnancy (less than 20 years old), uncontrolled fertility, low socioeconomic status, poverty, lack of female empowerment, lack of access to quality services, inadequate referral systems, and absolute lack of support from spouses.

Prevention of Maternal Mortality

Eighty percent (80%) of these deaths can be completely prevented through coordinated, long-term actions within families, health systems, and national legislation.

1. Primary Prevention

• Girl Child Education: Keeps girls in school, delays marriage, reduces pregnancies, and empowers them to demand employment and health rights.
• Proper Nutrition of the Girl Child: Prevents childhood malnutrition, which causes contracted pelvises and leads to severe Cephalopelvic Disproportion (CPD) during future labour.
• Family Planning: Eliminates unwanted pregnancies and criminal abortions. Enables couples to have children by choice, not by chance, avoiding the extreme risks of teenage pregnancies.
• Quality Antenatal Care: Timely attendance of at least 4 quality ANC visits to fully assess and properly manage any risk factors.
• Immunization: All women of reproductive age must be immunized against Tetanus and Hepatitis B.
• Information, Education, and Communication (IEC): Educating families on the specific causes of maternal mortality so individuals take proactive action rather than solely relying on the government.

2. Secondary Prevention

• A skilled attendant must be present at every single birth, supported by a functional referral system.
• Emergency Obstetric Care (EmOC) services must be provided and easily accessible.
• Improvement of transport networks and readily available ambulances.
• Equipping health facilities with functional operating theaters, blood storage, and a steady supply of essential drugs.
• Adequate referral systems so clients do not decline transfers out of fear of inadequate help at the next level.
• Proper evaluation and prompt reporting of maternal deaths (Maternal Death Audits).
• Decentralization of health services to make them available to rural women.
• Removal of barriers and implementation of policies that increase women's decision-making power.
• Recruitment of skilled staff to balance the workload, and organizing continuous refresher courses to improve the standard of care.

3. Tertiary Prevention

• The immediate control, medical management, and treatment of complications once they have already arisen (e.g., repairing severe lacerations or managing shock).
• Comprehensive Emergency Obstetric Care (CEmOC) interventions.

Maternal Morbidity

While death gets the most attention, maternal morbidity destroys lives. It is estimated that for every one maternal death, at least 15 more women suffer from severe morbidities. An optimistic 5 to 7 million women suffer a severely impaired quality of life from short-term or long-term disability.

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

Parameters of Maternal Morbidity

• Fever greater than 38°C
• Blood pressure greater than 140/90 mmHg
• Recurrent vaginal bleeding
• Hemoglobin (Hb) less than 10.5 g/dl irrespective of gestational age
• Asymptomatic bacteriuria of pregnancy

Classifications of Morbidity

• Direct Temporary (Mild): APH, PPH, eclampsia, obstructed labour, ruptured uterus, sepsis, ectopic pregnancy, and molar pregnancy.
• Direct Permanent (Chronic): Vesico-vaginal fistula (VVF), rectovaginal fistula (RVF), severe dyspareunia (painful intercourse), uterine prolapse, secondary infertility, and obstetric palsy.
• Indirect Morbidity: These conditions are expressions of previously existing diseases (like malaria, hepatitis, tuberculosis, anemia) that are heavily aggravated by the physiological changes of pregnancy.

Perinatal Mortality

Definition: Deaths among fetuses weighing 1000g or more at birth (greater than 28 weeks gestation) that die before or during delivery, or within the first 7 days of delivery. According to the WHO, the absolute limit of viability is a fetus weighing 500g (22 weeks).

The Perinatal Mortality Rate (expressed per 1000 total births) closely reflects the standards of medical care and the effectiveness of a country's social health measures.

Incidence

• Worldwide, nearly 4 million newborns die within the first week of life, and another 3 million are stillborn.
• Perinatal deaths could be reduced by at least 50% worldwide if key interventions are applied.
• In developed countries, it is less than 10 per 1000 total births; in developing countries, it is drastically higher due to malnutrition, infections, unregulated fertility, and poor obstetric care.
• The vast majority of fetal deaths (70-90%) occur before the onset of labour.

Predisposing Factors to Perinatal Mortality

• a) Maternal Epidemiology: Maternal age over 35 years, teenage pregnancies, multiparity, poverty, and poor maternal nutritional status.
• b) Medical Disorders: Severe anemia (Hb < 8g/dl), hypertensive disorders, syphilis, diabetes mellitus, malaria, other infections, prematurity, and fetal congenital malformations.
• c) Obstetric Complications: Antepartum hemorrhage (abruptio placentae alone is responsible for 10% of perinatal deaths due to severe hypoxia), pre-eclampsia/eclampsia (causes placental insufficiency), Rhesus iso-immunization, and cervical incompetence (leading to premature effacement between 24-36 weeks).
• d) Complications of Labour: Dystocia (from CPD, mal-presentation, abnormal uterine action) and Premature Rupture of Membranes (PROM) resulting in hypoxia, amnionitis, and birth injuries.
• e) Feto-Placental Factors: Multiple pregnancies (leading to preterm delivery), congenital and chromosomal abnormalities (responsible for 15% of deaths), and Intrauterine Growth Restriction (IUGR).
• f) Unexplained Causes: About 20% of stillbirths have absolutely no obvious fetal, placental, maternal, or obstetric causes.

Causes of Perinatal Mortality

• Infection: Sepsis, meningitis, pneumonia, congenital neonatal tetanus.
• Birth asphyxia and physical birth trauma.
• Severe Hypothermia.
• Prematurity and Low Birth Weight.
• Fatal Congenital Malformations.

Control and Prevention of Perinatal Mortality

Every baby has a right to be born alive, safe, and healthy. Interventions include:

• Pre-pregnancy healthcare, genetic counseling for high-risk cases, and prenatal diagnosis.
• Regular ANC with advice on health, diet, and rest.
• Early detection and management of maternal anemia, diabetes, and hypertension.
• Mandatory hospital delivery screening for clients of poor socioeconomic status, high parity, or extreme age.
• Careful monitoring of labour (partograph) to detect hypoxia or traumatic delivery early.
• Skilled birth attendance to eliminate neonatal sepsis.
• Provision of specialized neonatal referral services for preterm babies.
• Health education on early, exclusive breastfeeding and the strict prevention of hypothermia.
• Educating the community to fully utilize family planning and MCH services.
• Increased resource allocation and improving social infrastructure (transport, roads).
• Regular review of perinatal death cases (Perinatal Death Audits) and decentralization of MCH services.

Preconception Care

The outcome of a pregnancy depends immensely on the factors that operated during the entire period of growth and development of the mother from childhood. These include the circumstances surrounding her own birth, her birth weight, breastfeeding, childhood infections, formal education, socio-cultural practices, and reproductive health education.

Definition: Preconception care refers to the medical care and focus given to women and men during their reproductive years. It focuses on taking concrete steps now to protect the health of a baby they might have in the future. It is not just for those planning a pregnancy—it is about individuals getting and staying healthy overall, because unplanned pregnancies happen often.

Why is Preconception Care Important?

• For Healthy Babies: It gives babies the absolute best chance for a healthy start. Babies are less likely to be born prematurely, have a low birth weight, or suffer from severe birth defects.
• For Men: It means choosing to get healthy, protecting future children, and actively encouraging and supporting the health of their partner.
• For Healthy Families: The health of a family relies entirely on the health of the people in it. Taking care of your health now ensures a better quality of life for the family in the coming years.

Objectives of Preconception Care

• Assess clients' absolute readiness for pregnancy (mental, physical, and socio-economic readiness).
• Prevent, treat, and aggressively manage medical conditions that negatively affect pregnancy and the newborn.
• Prepare the body for a safe pregnancy and childbirth.
• Promote safer and responsible sexual behaviors.
• Promote the delay of the age at first pregnancy.
• Prevent HIV and other sexually transmitted diseases.

Services Offered During Preconception Care

1. Education and Information

• Sexuality, responsible parenthood, family planning, and STI/HIV prevention.
• Growth and development of the coming child, and education on pregnancy/childbirth.
• Malaria prevention, personal hygiene, and proper nutrition.
• The dangers of drug abuse and unprescribed medicine use during pregnancy.
• Education on managing previous health interventions (e.g., repair of VVF, ruptured uterus, infertility treatments, diabetes).

2. Screening and Managing Conditions

• Routine screening for HIV, Syphilis, Sickle cell diseases, Heart disease, Hypertension, Diabetes Mellitus, severe Anemia, and Mental illness.
• Screening for genetic congenital abnormalities.

3. Provision of Direct Medical Services

• Folic acid supplementation: Given for 3 months before pregnancy to prevent neural tube defects.
• Routine Immunization and Deworming for women.
• Management of STI/STDs and provision of long-lasting insecticide-treated nets (LLINs).
• Routine screening for reproductive health cancers (e.g., Pap smears for cervical cancer).
• Provision of Family Planning and VCT for HIV.

4. Support Channels

• Identifying and locating organizations that will support community groups.
• Appropriate counseling of individuals and couples about their specific pregnancy needs.
• Establishing a pre-pregnancy health profile for the purpose of long-term follow-up.
• Identifying special groups (e.g., women with disabilities, adolescents, and HIV-infected women) and developing appropriate interventions for them.
• Mobilizing and sensitizing the community to be highly supportive of the needs of these special groups.
• Promoting responsible motherhood, fatherhood, and contraception information.

Where Preconception Care is Done and How to Reach Out

Preconception care is heavily conducted in Health Units and through Community-based groups. The best ways to reach out to special groups include:

• Direct health education in the community.
• Mass media campaigns (Radio/TV).
• Church and religious groups.
• Appropriate ITC (Information, Technology, and Communication) materials.
• Engagement of powerful community opinion leaders.