A matter of life and death

The Core Issue: Delays at multiple levels in seeking and receiving maternal healthcare contribute significantly to maternal mortality. Collaborative efforts between communities and healthcare providers are crucial to reducing these delays, saving lives, and promoting safe motherhood.

Three Critical Delays

1. Delay in Deciding to Seek Care:

   • Lack of Information: Limited awareness of available health services.

   • Communication and Physical Barriers: Language differences, difficult terrain (e.g., mountains, lakes), poor road infrastructure.

   • Resource Constraints: Financial limitations, absence of a spouse/partner for support, and transportation difficulties.

   • Inappropriate Care-Seeking: Prioritizing traditional birth attendants (TBAs) over skilled medical professionals.

   • Decision-Making Delays: Mothers waiting for a husband’s permission or financial assistance.

2. Delay in Reaching a Health Facility:

   • Distance: Long distances to the nearest health facility.

   • Transportation Issues: Lack of available, timely, or affordable transportation.

   • Poor Road Conditions: Impassable or poorly maintained roads.

3. Delay in Receiving Adequate Care:

   • Staff Shortages and Skill Gaps: Insufficient trained healthcare workers, particularly in managing high-risk pregnancies.

   • Drug and Supply Shortages: Lack of essential medications (e.g., antibiotics, blood for transfusion) and supplies.

   • Equipment Deficiencies: Missing or non-functional equipment (e.g., sterile supplies, syringes).

   • Limited Service Availability: Inadequate range of services offered at health facilities.

Factors Influencing Delays

1. Family Dynamics:

   • Young or single mothers may hesitate to seek care due to fear or lack of awareness.

   • Decision-making delays due to the absence of a husband or influence of in-laws.

2. Socioeconomic Status: Poverty limits access to healthcare and resources.

3. Education Level: Lower education levels correlate with decreased awareness of healthcare options.

4. Geographic and Environmental Barriers: Rivers, mountains, floods, and other natural obstacles.

5. Security Concerns: Conflict and instability restrict access to healthcare.

Maternal mortality: A GLOBAL CRISIS

Definition: Maternal mortality is the death of a woman while pregnant or within 42 days of the end of pregnancy from any cause related to or aggravated by the pregnancy or its management (excluding accidental or incidental causes).

Maternal Mortality Rate: The number of maternal deaths per a specific number (often 100,000) of live births in a given period (usually a year).

Incidence:

• Globally, approximately 8 million women experience pregnancy-related complications annually, with over half a million dying.

• 99% of maternal deaths occur in developing countries.

• The risk of a woman dying from pregnancy-related causes is significantly higher in developing countries (1 in 11) compared to developed countries (1 in 5,000).

• For every maternal death, at least 16 more women suffer severe health complications.

Uganda’s Situation:

• Maternal mortality rates have declined but remain high (435/100,000 in 2011).

• Concerted efforts are needed to further reduce these rates.

Factors Contributing to High Maternal Mortality in Uganda

1. Poverty: Limits access to basic needs, healthcare, and emergency transport.

2. Gender Inequality: Male dominance in decision-making, including healthcare seeking, restricts women’s autonomy.

3. Inadequate and Inaccessible Health Services: Limited facilities equipped for obstetric care, long distances to access care.

4. Health Worker Shortages: Insufficient trained health workers lead to long wait times and discourage women from seeking care.

5. Negative Attitudes of Health Workers: Rude or unfriendly behavior deters women.

6. Early Marriage: Child brides face higher risks due to underdeveloped bodies.

7. Illiteracy: Limits women’s ability to advocate for their reproductive health rights.

8. Harmful Traditional Practices: Certain beliefs and practices (e.g., food taboos, female genital mutilation) increase risks.

9. Poor Infrastructure: Inadequate transportation and communication networks hinder access to care, especially in rural areas.

10. High Child Mortality: Leads to a desire for larger families, increasing the number of pregnancies and associated risks.

11. Desire for Large Families: Cultural value placed on having many children.

12. Sex Preferences: Continued childbearing to achieve a desired gender balance.

13. High Fertility Rate: Uganda’s high fertility rate (7 children per woman) increases lifetime risk.

14. Underutilization of Existing Services: Due to factors listed above.

15. Inadequate Supplies: Shortages of essential drugs and equipment.

16. Poor Referral Systems: Lack of effective emergency referral mechanisms.

17. Lack of Male Involvement: Limited support and participation from husbands/partners.

18. Ignorance/Lack of Awareness: Limited knowledge about pregnancy risks and healthcare options.

19. Disrespect for Human Rights: Limited respect for women’s right to health.

20. Gender Stereotypes: These compound many of the factors listed above.

Causes of Maternal Mortality (Uganda)

• Direct Causes:

  • Sepsis: Infection following childbirth, especially in unsanitary conditions or with prolonged labor.

  • Hemorrhage: Excessive bleeding, particularly dangerous in anemic women.

  • Early Pregnancy Deaths: Ectopic pregnancies and unsafe abortions.

  • Hypertensive Disorders: Pre-eclampsia and eclampsia.

  • Other: Thrombosis, thrombo-embolism, genital trauma.

• Indirect Causes:

  • Cardiovascular Diseases: Pre-existing heart conditions.

  • HIV/AIDS: Weakened immune system.

  • Malnutrition: Nutrient deficiencies.

  • Diabetes: Complications related to blood sugar control.

  • Thyroid Diseases: Hormonal imbalances.

  • Anemia: Low red blood cell count.

Predisposing Factors

• Early pregnancy (under 20 years)

• Uncontrolled fertility

• Low socioeconomic status

• Lack of access to quality healthcare

• Inadequate referral systems

• Lack of spousal support

Prevention of Maternal Mortality

Primary Prevention (Before Pregnancy)

1. Girl Child Education: Promotes later marriage, fewer pregnancies, and economic empowerment.

2. Proper Nutrition: Adequate nutrition during childhood and adolescence is vital for healthy development.

3. Family Planning: Enables women to have children by choice, reducing unwanted pregnancies and unsafe abortions.

4. Quality Antenatal Care: Early identification and management of risk factors.

5. Immunization: Tetanus and Hepatitis B vaccinations for women of reproductive age.

6. Health Education: Empowering individuals and families with knowledge about maternal health.

Secondary Prevention (During Pregnancy and Childbirth)

1. Skilled Birth Attendants: Ensuring the presence of trained professionals at every birth.

2. Emergency Obstetric Care: Accessible and functional emergency services.

3. Improved Transport and Communication: Enhancing infrastructure for timely access to care.

4. Equipped Health Facilities: Adequate equipment, functional operating theaters, and blood banks.

5. Effective Referral Systems: Streamlined processes for transferring patients to higher levels of care.

6. Maternal Death Reviews: Thorough evaluation of maternal deaths to identify areas for improvement.

7. Decentralization of Services: Making services available closer to communities.

8. Removal of Barriers: Addressing financial, social, and cultural barriers to healthcare access.

9. Staff Recruitment and Training: Increasing the number of skilled healthcare workers and providing ongoing training.

Tertiary Prevention (Managing Complications)

1. Management of Complications: Effective treatment of complications that arise during pregnancy or childbirth.

2. Emergency Obstetric Care: Prompt and appropriate emergency care.

Obstetric morbidity

Definition: Obstetric morbidity refers to any health condition attributed to and/or aggravated by pregnancy and childbirth that has a negative impact on the woman’s well-being. It can occur during the antepartum, intrapartum, or postpartum period (up to 42 days after delivery).

Parameters:

• Fever above 38°C

• Blood pressure above 140/90 mmHg

• Recurrent vaginal bleeding

• Hemoglobin (Hb) less than 10.5 g/dl

• Asymptomatic bacteriuria

Classification:

• Direct Obstetric Morbidity:

  • Temporary (Mild): APH, PPH, eclampsia, obstructed labor, ruptured uterus, sepsis, ectopic pregnancy, molar pregnancy.

  • Permanent (Chronic): Vesicovaginal fistula (VVF), rectovaginal fistula (RVF), dyspareunia, prolapse, secondary infertility, obstetric palsy.

• Indirect Obstetric Morbidity: Aggravation of pre-existing conditions (e.g., malaria, hepatitis, tuberculosis, anemia) by pregnancy.

Perinatal  Mortality

Definition: Deaths of fetuses weighing 1000g or more (or over 28 weeks gestation) that occur before, during, or within the first 7 days of delivery. The perinatal mortality rate is expressed per 1000 total births.

Incidence:

• Globally, around 4 million newborns die within the first week, and another 3 million are stillborn.

• Perinatal deaths could be reduced by at least 50% with key interventions.

• Rates are significantly higher in developing countries.

Predisposing Factors in Uganda

• Maternal Factors:

  • Epidemiology: Advanced maternal age (over 35), teenage pregnancy, high parity, poverty, poor nutrition.

  • Medical Disorders: Anemia, hypertensive disorders, syphilis, diabetes, malaria, other infections.

  • Obstetric Complications: Antepartum hemorrhage (APH), pre-eclampsia/eclampsia, Rh isoimmunization, cervical incompetence.

  • Labor Complications: Dystocia, premature rupture of membranes (PROM).

• Feto-placental Factors:

  • Multiple pregnancy

  • Congenital malformations

  • Intrauterine growth restriction (IUGR)

  • Low birth weight

• Unexplained Causes: About 20% of stillbirths have no identifiable cause.

Causes of Perinatal Mortality

• Infection (sepsis, meningitis, pneumonia, neonatal tetanus)

• Birth asphyxia and trauma

• Hypothermia

• Prematurity/low birth weight

• Congenital malformations

Control and Prevention

1. Pre-pregnancy Health Care and Counseling: Addressing health issues before conception.

2. Genetic Counseling: For high-risk cases.

3. Regular Antenatal Care: Monitoring and managing pregnancy risks.

4. Hospital Delivery for High-Risk Cases: Ensuring access to specialized care.

5. Careful Labor Monitoring: Detecting and managing fetal distress.

6. Skilled Birth Attendance: Reducing infection risks.

7. Neonatal Referral Services: Specialized care for preterm and sick newborns.

8. Health Education: Promoting breastfeeding and newborn care.

9. Family Planning: Spacing pregnancies and reducing risks.

10. Increased Resource Allocation: Funding for maternal and child health services.

11. Perinatal Death Reviews: Identifying gaps and improving care.

12. Improved Infrastructure: Enhancing healthcare access, transport, and communication.

13. Decentralization of Services: Bringing care closer to communities.

Preconception Care

Definition: Care for women and men during their reproductive years, focusing on improving health to optimize future pregnancy outcomes. It benefits all individuals, regardless of their plans to have children, by promoting overall health and well-being.

Importance:

• Healthy Babies: Reduces the risk of preterm birth, low birth weight, birth defects, and other complications.

• Healthy Families: Promotes the overall health and well-being of families.

Objectives

1. Assess readiness for pregnancy (mental, physical, socioeconomic).

2. Prevent, treat, and manage medical conditions affecting pregnancy.

3. Prepare for pregnancy and childbirth.

4. Promote safer sexual behaviors.

5. Promote delayed first pregnancy.

6. Prevent HIV and STIs.

Services Offered

1. Education and Information: Sexuality, child development, pregnancy, responsible parenthood, family planning, STIs/HIV, malaria prevention, hygiene, nutrition, drug use, previous health interventions.

2. Screening and Management: HIV, syphilis, sickle cell disease, heart disease, hypertension, congenital abnormalities, anemia, diabetes, mental illness.

3. Provision of Services: Folic acid supplementation, immunization, deworming, STI management, insecticide-treated nets, reproductive health cancer screening, family planning, voluntary counseling and testing (VCT) for HIV.

4. Support Channels: Identifying support organizations, counseling, establishing pre-pregnancy health profiles, addressing the needs of special groups (e.g., disabilities, adolescents, HIV-positive individuals).

5. Responsible Parenthood: Education and support for both mothers and fathers.

6. Contraception and Family Planning: Information and access to services.

Where to Access Preconception Care

• Health units

• Community-based groups

Outreach to Special Groups

• Health education

• Mass media

• Church groups

• Information, education, and communication (IEC) materials

• Opinion leader