Maternal mortality in developing countries

The authors of this letter respond to earlier letters prepared in response to their article on maternal mortality in developing countries. It is conceded that maternal mortality is high in India and Bangladesh; however, statistics from Gambia are based on small populations and are therefore inconclusive. It is noted that a 7-year survey of 4000 households in Machakos, Kenya, where 73% of deliveries occurred at home, yielded a maternal mortality rate of only 0.8/1000 deliveries. Finally, it is asserted that the measurement traditionally used in estimating maternal mortality for many African countries (ratio of recorded maternal deaths to recorded deliveries) is misleading. Maternal deaths are more likely than deliveries to be recorded. In Niger, the number of maternal deaths increased from 1980 (374) to 1982 (484). The ratio of maternal deaths to expected live births also increased from 135 to 166/100,000, whereas the traditionally calculated maternal mortality rate decreased from 519 to 420/100,000 due to changes in the denominators. It is recommended that health authorities of African countries such as Niger consider setting an absolute number of maternal deaths below which they would try to bring the current toll.     

Maternal mortality and morbidity in the developing countries like India

Safe motherhood will require a multi-faceted strategy of improving girls' education and employment opportunities, providing primary and reproductive health care for women, taking a high risk approach with referral for all at-risk pregnant women, and including maternal mortality as part of the quality of life index. The World Health Organization in 1986 reported that 99% of maternal mortality occurred in developing countries: 640 per 100,000 live births in Africa, 420/100,000 in Asia, 270/100,000 in Latin America, 100/100,000 in Oceania, 450/100,000 in developing countries on average, and 30/100,000 in developed countries. The chances of maternal death ranges in the extremes from 1/9850 in northern Europe to 1/21 in Africa. In India, the chance of maternal mortality was estimated at 1/18; the surviving also might suffer from perineal tears, genital infections, uterovaginal prolapse, and vesico-vaginal fistula. Direct obstetric causes include those directly related to pregnancy, labor, and the postpartum period. Indirect causes include those resulting from previous existing diseases that were aggravated by the pregnancy. 75% of maternal mortality was caused by hemorrhage, obstructed labor, infection, eclampsia, and abortion. Proper handling could prevent maternal mortality in an estimated 63-80% of direct causes and 88-98% of all causes. Risk factors for postpartum hemorrhage include multiparity, age over 35 years with stretched uterus, and slight episodes of bleeding. Treatment must be immediate and sustained with oxytocic drugs and plasma expanders; the means of referral to an equipped facility must be available to women with hemorrhage. Risk factors for obstructed labor include very young age, height below 145 cms, previous prolonged labor or stillbirth, and previous cesarean, abnormal presentation, or labor progression. Delivery for these women must be in a facility offering trained doctors and well-equipped operating rooms. Prevention of infection is possible with pre-sterilized delivery kits, antibiotics in kits or within facilities, cleanliness of hands and delivery areas, and maternal tetanus immunization. Identification of edema in pregnancy would prevent eclampsia. Abortion complications could be prevented with safe and early practices and women's control over fertility.     

Maternal immunisation in developing countries

Maternal immunisation could help to prevent the 2-3 million neonatal and early infant deaths that occur in the developing world each year. Determining the causes of neonatal and early infant deaths in developing countries is difficult as most occur at home. However, it is likely that at least half are due to infections, several of which might be prevented by maternal immunisation. Even in poor countries with few health facilities, a high percentage of pregnant women attend an antenatal clinic at least once during pregnancy. Thus, an effective delivery system for maternal immunisation already exists and, because of the success of maternal tetanus immunisation, this approach to the prevention of serious illness or death in young infants is widely accepted by the general population. However, the high prevalence of HIV and malaria found in pregnant women in some parts of the developing world, especially sub-Saharan Africa, could have an effect on the efficacy of maternal immunisation as both of these infections adversely affect placental function. Nevertheless, the potential of maternal immunisation to prevent early infant deaths in developing countries needs to be fully explored. The incidence of pneumococcal infections is high in many developing countries and about 25% of these infections occur at an age before protection could be anticipated following vaccination with a pneumococcal conjugate vaccine in infancy. Thus, a strong case can be made for a trial of the effectiveness of maternal immunisation with a pneumococcal vaccine in preventing serious illness or death in young infants in developing countries.     

Reducing perinatal mortality in developing countries

The perinatal mortality rate (PNMR) is a key health status indicator. It is multifactorial in aetiology and is significantly influenced by the quality of health care. While there is an ethical imperative to act to improve quality of care when deficiencies are apparent, the lack of controls--when an interventions is applied to an entire service--makes it difficult to infer a causal relationship between the intervention and any subsequent change in PNMR. However, by specifically measuring avoidable perinatal deaths (those due to error or omission on the part of the health service), this limitation is partially overcome, and the impact of the intervention can be more rigorously evaluated. This paper reports the impact of perinatal audit in a rural African health district between 1991 and 1995. A total of 21,112 consecutive births were studied: the average number of deliveries increased by 31% from 325 to 424 per month. The PNMR (birth weight > or = 1000g) in 1991 was 27/1000, increased to 42/1000 in 1992, and fell steadily to 26/1000 in 1995 (40% reduction; p = 0.002). The proportion of avoidable deaths fell from 19% in 1991 to zero in the second half of 1995 (p = 0.0008). While factors associated with perinatal mortality are many, complex, and interrelated, this report suggests that mortality can be reduced significantly in resource-poor settings by improving quality of health care. Including the measurement of avoidable deaths in perinatal audit allows the impact of interventions to be more rigorously assessed than by simple measuring the PNMR.     

Reproductive mortality in two developing countries.

Reproductive mortality includes mortality attributable to pregnancy, termination of pregnancy, childbirth and its sequelae, and contraception. Reproductive mortality has been estimated for the United Kingdom, the United States, and for states of the US. However, it has not previously been measured for developing countries, where maternal mortality often remains distressingly high. This paper reports on data from one governorate of Egypt, where reproductive mortality was 46 per 100,000 married women ages 15-49 (2.2 per cent of this was attributable to contraception), and one province of Indonesia, where reproductive mortality was 70 per 100,000 (of which 1.4 per cent was due to contraception). In both locations, complications of pregnancy and childbirth were a leading cause of death in the age group studied (the first cause in Indonesia, second in Egypt). Contraceptive prevalence was 24 per cent of married women ages 15-49 in Egypt and 48 per cent of this age group in Indonesia.     

Child mortality in the developing countries of Africa

Infant mortality statistics in developing African countries are reviewed. According to the World Health Organization (WHO) surveys, there was an overall decrease in infant mortality from 1960-1986, although the infant mortality rate in the African region remains higher than in other WHO regions (119.4, compared with 40.6 in the European region, 11.8 in the Eastern Mediterranean region, 110.2 in the South- Eastern Asia, 49.7 in the American Region, and 44.5 in the Western part of the Pacific ocean). In infants younger than 28 days old, mortality is associated with pregnancy and labor complications, congenital birth defects, and birth trauma. In Algeria, Sierra Leone, Nigeria, Mozambique, Malawi, and Zimbabwe, 70-90% of all deaths were caused by tetanus (70-80% of African women give birth at home without any medical help). In a 1 month to 1 year old age group, the leading cause of mortality is diarrhea (52% in Sudan, 29.2% in Sierra Leone); other causes of death are measles (15.8%), acute respiratory diseases (14.3%), malaria (8.5%), and infectious meningitis (6%). In a 1-4 years old age group, leading cause of mortality is nutritional deficiencies (9%). In addition to medical causes, infant mortality is also associated with a number of socioeconomic factors: insufficient nutrition of mothers, heavy physical work during pregnancy, young age of mothers and short interval between pregnancies, lack of proper medical care during pregnancy and labor, and early switching to infant formula not following proper hygienic recommendations.     

Estimating child mortality due to diarrhoea in developing countries

OBJECTIVE: The major objective of this study is to provide estimates of diarrhoea mortality at country, regional and global level by employing the Child Health Epidemiology Reference Group (CHERG) standard. METHODS: A systematic and comprehensive literature review was undertaken of all studies published since 1980 reporting under-5 diarrhoea mortality. Information was collected on characteristics of each study and its population. A regression model was used to relate these characteristics to proportional mortality from diarrhoea and to predict its distribution in national populations. FINDINGS: Global deaths from diarrhoea of children aged less than 5 years were estimated at 1.87 million (95% confidence interval, CI: 1.56-2.19), approximately 19% of total child deaths. WHO African and South-East Asia Regions combined contain 78% (1.46 million) of all diarrhoea deaths occurring among children in the developing world; 73% of these deaths are concentrated in just 15 developing countries. CONCLUSION: Planning and evaluation of interventions to control diarrhoea deaths and to reduce under-5 mortality is obstructed by the lack of a system that regularly generates cause-of-death information. The methods used here provide country-level estimates that constitute alternative information for planning in settings without adequate data.     

Maternal mental health and child nutritional status in four developing countries

OBJECTIVE: To test the hypothesis that maternal common mental disorders (CMD) are associated with poorer child nutritional status in four developing countries (Ethiopia, India, Vietnam, and Peru). DESIGN: Community based cross sectional survey in 20 sites in each of the four countries. Maternal CMD measured by the self reporting questionnaire 20 items (SRQ20). Potential confounding factors include: household poverty, household composition, maternal characteristics such as age and education, child characteristics such as birth weight, age, and sex. Possible mediating factors included the child's physical health and breast feeding status. SETTING: Urban and rural, poor and middle income areas in each country. PARTICIPANTS: 2000 mothers and their children aged 6-18 months in each country. MAIN OUTCOME MEASURES: Child stunting and underweight measured using standard anthropometric techniques. RESULTS: Levels of maternal CMD and child malnutrition are high in each study setting. After adjusting for confounding factors, the odds ratios (OR) for the association of maternal CMD with child stunting are: India 1.4 (95%CI 1.2 to 1.6), Peru 1.1 (0.9 to 1.4), Vietnam 1.3 (0.9 to 1.7), and Ethiopia 0.9 (0.7 to 1.2). For child underweight, the confounder adjusted ORs are: India 1.1 (0.9 to 1.4), Peru 0.9 (0.6 to 1.2), Vietnam 1.4 (1.1 to 1.8), and Ethiopia 1.1 (0.9 to 1.4). No clear evidence for effect modification by the child's age or sex was found. Possible mediating factors for the effect of maternal CMD on child malnutrition did not provide strong suggestions for potential mechanisms. CONCLUSIONS: There was a relation between high maternal CMD and poor child nutritional status in India and Vietnam. However, the findings from Peru and Ethiopia do not provide clear evidence for a similar association being present in non-Asian countries. Regardless of the direction of the relation, child nutrition programmes in Asia should consider incorporating promotion of maternal mental health.     

Maternal social capital and child nutritional status in four developing countries

Social capital has been shown to be positively associated with a range of health outcomes, yet no studies have explored the association between maternal social capital and child nutritional status. Using data from the Young Lives study comprising 7242 1-year-old children from Peru, Ethiopia, Vietnam and the state of Andhra Pradesh in India, we find significant differences in the levels of, in particular, structural social capital (group membership and citizenship) between countries. While few associations were found between structural measures of social capital, support from individuals and cognitive social capital (e.g. trust, social harmony) displayed fairly consistent positive associations with child nutritional status across countries.     

Long-term trends in fetal mortality: implications for developing countries

This paper discusses the problems of defining and measuring late-fetal mortality (stillbirths). It uses evidence from 11 developed countries to trace long-term trends in fetal mortality. Issues associated with varying definitions and registration practices are identified, as well as the range of possible rates, key turning points and recent convergence. The implications for developing countries are spelled out. They emphasize the possible limitations of WHO estimation methods and survey-based data by examining the cross-sectional associations among 187 countries in the year 2000. The important role of skilled birth attendants is emphasized in both data sets, but the different effects on maternal mortality and late-fetal mortality are also noted.     

Socioeconomic and health effects on mortality declines in developing countries

It has been argued that mortality declines in developing countries have not been associated with social and economic factors because of the diffusion from the developed countries to the developing countries of health and medical techniques. This paper examines the relationship between socioeconomic development and health and mortality declines in developing countries which are in two different stages of the demographic transition. A path model linking socioeconomic and health variables and mortality is developed and tested for early and late transition nations. The empirical findings indicated that the network of socioeconomic variables and their effects on mortality were much more significant in late transition countries than in early transition countries. While the impact of health services on crude death rates is large in the early transition nations, its impact declines considerably as countries reach a more transitionally 'mature' stage.