Maternal deaths a big challenge [Archives:2006/966/Health]

July 24 2006

Amel Al-Ariqi
[email protected]

A 20-year-old woman from Sawan area, 1 km. from Sana'a, died in a poor socioeconomic state. Pregnant for the full term, she labored at home for seven hours before going to a public hospital. However, she wasn't admitted because the on-duty doctor said no empty beds were available.

So, her husband took her to another Sana'a hospital where she was admitted and observed for six hours. After this period, due to elevated blood pressure and fatal distress indicating poor progress of her labor, doctors decided she needed a Caesarean section. So a Caesarean was done and a son was born.

However, severe postpartum hemorrhaging occurred immediately after the delivery. Doctors tried to stop the bleeding with drugs and sutures. A woman doctor thought homeostasis might have been achieved, so the uterus and abdomen were closed but vaginal bleeding continued for an hour.

An obstetric consultant was called and blood was prepared from the blood bank. When doctors decided to open the abdomen, they found there was internal hemorrhaging, so a total abdominal hysterectomy was performed. The patient received seven units of blood, but unfortunately, her condition was so bad that she died following the operation.

Another 20-year-old woman from Beit Khiran village, 20 km. from Sana'a, died in a similar poor socioeconomic state. Also pregnant for the full term, her son was delivered at home, with her mother-in-law as the attendant. The boy was born alive, but the placenta wasn't delivered completely and postpartum hemorrhaging occurred for three hours. She then was transferred to a hospital, but she fell unconscious enroute and died before reaching the hospital.

These two stories are of two different women who may never have met; however, they faced the same destiny. Both died during delivery and became statistics in a study entitled, “Maternal Mortality Surveillance.”

Conducted in only 20 villages in Sana'a and Amran governorates, the study included maternal death cases during pregnancy, labor and postnatal during the period July 10 to December 31, 2004. Collected data was obtained from the relatives of the deceased, who saw the mothers from the time of labor and followed their progress to the time of death.

Details of the two cases, which were chosen randomly from 23 cases mentioned in the study, pointed to the difficulties and complications some mothers face while giving birth and leading up to their death. However, such details won't ever be able to describe the pain and suffering these women endured before their deaths. Nobody can determine the true loss their deaths inflicted upon their families. They are among hundreds who die annually in Yemen as a result of complications during pregnancy and delivery.

Varying statistics, one common fact

Due to contradicting statistics resulting from different data collections, there's a lack of comprehensive studies on maternal mortality in Yemen. Thus, in the absence of reliable data, it's difficult to outline a policy to address the problem.

Recent official government figures estimate maternal mortality at 351 per 100,000 live births, whereas UNICEF and WHO estimate it as much higher, at 1,400 per 100,000 live births, thereby accounting for 42 percent of all deaths among Yemeni women of childbearing age.

Statistics yield varying numbers regarding delivery locations and available medical care, with each program or project regarding motherhood in Yemen offering different statistical data. For example, the 2004 Pan-Arab Project for Family Heath Statistics stated that 77.2 percent of all births occur at home, 16.1 percent at governmental hospitals, 3.5 percent at a private hospital or clinic and 3.2 percent in other locations.

However, a recent baseline survey conducted for the Saving Mothers' Lives in Yemen project indicated that 62 percent of deliveries occur at home, rising to 68 percent in rural areas and 53 percent in urban areas. Additionally, survey results indicated that more than 37 percent of births face health problems during delivery.

The 2004 Pan-Arab Project for Family Health Statistics also showed that 55 percent of mothers didn't receive any prenatal care and 87 percent didn't seek any type of postnatal care. However, the Saving Mothers' Lives in Yemen baseline survey indicated that 44 percent didn't receive any prenatal care and 57 percent didn't seek any type of postnatal care.

According to a 2003 study on Yemeni female health, 18 percent of maternal deaths occurred during pregnancy, whereas 82 percent occurred during delivery and the postpartum period. Only 16 percent of births took place in health facilities, while 84 percent were attended at home by mothers and mothers-in-law.

Although these surveys yielded differing statistical findings, all agreed that Yemen has one of the world's highest maternal mortality rates.

Causes and results

In Yemen and elsewhere, evidence suggests that the highest burden of poor maternal health falls on the poorest women.

The 2004-2005 Maternal Mortality Surveillance assured that most of the cases mentioned were related to poor socioeconomic states. Additionally, the study showed that Yemen's high maternal mortality also reflects both the poor status of the health system, as well as social and economic conditions that deny women their fundamental rights to survive pregnancy and childbirth.

In general, the public health sector suffers extremely insufficient infrastructure, lack of human resources, an inefficient referral system and lack of emergency obstetric services. Primary health care coverage isn't comprehensive, as such facilities usually are staffed by inadequately trained personnel, poorly equipped and insufficient availability of drugs and medical supplies.

Yemeni women exhibit unusually high-risk reproductive health – too early, too close together and, too often, too late. Moreover, the dowry system puts pressure on young brides to prove their fertility. Some 12 percent of Yemeni women in the 15-19 age group already have given birth to one child.

Complex interaction between extreme poverty, illiteracy, weak transportation infrastructure and geographical and social isolation contributes significantly to the decision not to seek prenatal and postnatal care or even hospital treatment when complications arise during delivery.

Due to these circumstances, pregnant women are subjected to postpartum hemorrhaging, prolonged labor, blood clotting problems, distended uterus, rapid pulse, low blood pressure, weakness, fainting and shock, toxemia, infections, high blood pressure and fever, according to the studies. WHO studies conclude that hemorrhaging is the main cause of maternal deaths in Yemen, followed by infection and then the risk of a ruptured uterus.

Steps to face the challenge

Yemen is one of the nations committed to achieving Millennium Development Goals by 2015. One main goal is to improve maternal health, which means reducing the maternal death rate. To reach this goal, Yemen must rid itself of the causes and circumstances of the situation, such as poverty, illiteracy, weak infrastructure and a poor health system. Thus, achieving this goal isn't easy; however, it's not impossible to come close to reaching it.

For example, many national and international organizations and associations undertake midwife training for women in remote Yemeni areas, providing them with medical supplies and communication tools like cell phones so they can be in touch with their organizations. These midwives also are trained to offer medical consultation to pregnant women in both prenatal and postnatal periods.

This is considered a big step, as evidence shows that most life-threatening complications can't be predicted or prevented, but almost all can be treated successfully with well-timed medical care.