Followup: Maternal and Newborn Health

I just want to send out a few more items that may be helpful to those of you interested in learning about maternal and newborn health. Let's start in the U.S. In my last post I gave you the link to UNICEF's State of the World's Children address, but the publication offers little information about maternal mortality in the U.S. We need information about domestic maternity care, because the maternal mortality rate in the U.S. is currently the worst it has been in decades. One resource that offers great information (from mothers' perspectives) about maternity and postpartum care is Childbirth Connection's New Mothers Speak Out Report. Click on the link to read more about childbirth in America.

Moving back to international issues of maternal and newborn health: This video made me smile. You can read more about this awareness-raising campaign at Oxfam UK's website.



Also, might I recommend this photo gallery?

Issue: Maternal and Newborn Health

The United Nations Children's Fund (UNICEF) recently released their annual report, The State of the World's Children, for 2009. Every year this report offers an in-depth look at one particular issue affecting children around the world. This year the report is entitled "Maternal and Newborn Health," and it assesses the health and well-being of pregnant women and new mothers and their babies around the world.

Doesn't the picture on the front sort of make your heart grow a few sizes?

I'm going to try to offer an overview of some of the issues presented in SOWC 2009, but obviously my efforts will be limited; the report is 158 pages long, packed with information. I really encourage you, if you're interested in this subject, to click here to read the report. You can view it as a pdf file or request a paper copy. The blocks of italics in this post are direct quotes from SOWC.

"In the developing world as a whole, a woman has a 1 in 76 lifetime risk of maternal death, compared with a probability of just 1 in 8,000 for women in industrialized countries. By way of comparison, the lifetime risk of maternal mortality ranges from just 1 in 47,600 for a mother in Ireland, to 1 in every 7 in Niger, the country with the highest lifetime risk of maternal death."

When we're talking about maternal deaths (the term used to describe deaths that occur during labor or as a result of labor), there are two types of causes. "Direct causes" are obstetric complications (like post-partum hemorrhage, infections, eclampsia, or obstructed labor), or complications from abortions. These causes may be labeled as actually causing the mother's death. But there are numerous other "indirect causes," as well, which contribute to the emergence of these direct causes. Common indirect causes of maternal death include:

*Anemia
*Poor nutrition
*Lack of birth spacing (e.g., having too many babies one after another, without giving the body time to recuperate)
*Malaria
*Iodine deficiency
*HIV/AIDS
*Undeveloped anatomy (e.g., young girls whose bodies are not developed enough to bear children)
*Inadequate hygiene (which can cause maternal-neonatal tetanus)
*Poverty

In other words, if a woman is sick and weak and undernourished, her chances of having a normal, uncomplicated labor are greatly diminished. This list is partial; there are many other factors--both biological and socio-cultural--that make labor more dangerous than it needs to be.

Obviously, the health of the laboring woman/new mother is inextricably linked with the health of her baby. These factors that contribute to unusually dangerous labors and serious health problems also contribute to health problems and deaths for newborn babies.

"The latest estimates from the World Health Organization, which date from 2004, indicate that around 3.7 million children died within the first 28 days of life in that year. Within the neonatal period, however, there is wide variation in mortality risk. The greatest risk is during the first day after birth, when it is estimated that between 25 and 45 percent of neonatal deaths occur. Around three quarters of newborn deaths, or 2.8 million in 2004, occur within the first week – the early neonatal period."

The ten countries with the highest death rate for children under the age of 5 are:
1. Sierra Leone
2. Afghanistan
3. Chad
4. Equatorial Guinea
5. Guinea-Bissau
6. Mali
7. Burkina Faso
8. Nigeria
9. Rwanda
10. Burundi

"Some 86 per cent of newborn deaths globally are the direct result of three main causes: severe infections – including sepsis/pneumonia, tetanus and diarrhoea – asphyxia and preterm births. Severe infections are estimated to account for 36 per cent of all newborn deaths. They can occur at any point during the first month of life but are the main cause of neonatal death after the first week."

There are so many ways to promote maternal and newborn health. One of the crucial keys is prenatal care and adequate nutrition. When women are well-nourished and healthy, most labors proceed well without complications. However, this is not as simple as it sounds; the current and ongoing World Food Crisis that is driving food prices up around the world is making it difficult for women to meet their basic nutritional needs, let alone consume the extra calories that pregnant women need. And lack of access to basic health care for infections and illnesses (such as malaria) makes women even more vulnerable to complications.

One crucial element to decreasing maternal and newborn mortality is to provide training and resources to traditional birthing assistants, or midwives. Training programs (like this one, in Afghanistan) can integrate traditional and modern knowledge about childbirth, and provide midwives with much-needed supplies (like soap, clean towels, razor blades, receiving blankets, etc.) and training on techniques they may not be familiar with (such as infant resuscitation). Increasing pregnant women's access (before, during, and after labor) to trained labor assistants can ultimately result in the following crucial elements:

*Better management of infectious diseases (Prevention of malaria has been shown to decrease premature births!)
*Ongoing promotion of breastfeeding
*Prenatal and antenatal visits and assistance
*Improved hygiene practices
*Treated mosquito nets to prevent malaria infections in mothers and newborns
*Kangaroo mother care (e.g., skin-to-skin contact and on-demand breastfeeding) for low-birthweight babies

And of course, it's important to improve access to emergency obstetric care for babies and women with life-threatening conditions. Then, some of the best ways to promote child survival are to ensure that the child is exclusively breastfed, provide access to basic health care and immunizations, and prevent the child from contracting diseases like malaria.

Let me just give one example of how adequate prenatal care and effective care-provider training can work together. In Africa and Asia, over 30 percent of maternal deaths result from postpartum hemorrhage. The risk of hemorrhage is greatly decreased when a woman is healthy and nourished, and a few basic techniques can prevent hemorrhage. For example, the World Health Organization recommends delaying the clamping and cutting of the umbilical cord until it stops pulsing; this alone significantly decreases the risk of hemorrhage.

In addition to all these logistical factors, there are many socio-cultural factors that need to be dealt with to improve women's and babies outcomes. Here are a few things that have been proven to have a positive effect on maternal and newborn health, according to SOWC:

*Increasing educational opportunities for girls
*Decreasing gender discrimination (and letting women make choices about their health care, rather than having those choices dictated by husbands or communities)
*Preventing child marriage and early child-bearing by undeveloped girls
*Abandoning female genital mutilation (which causes many extra complications for child-bearing, e.g., accelerating the risk of post-partum hemmorhage and obstetric obstruction)
*Involving men and adolescent boys in maternal and newborn health and care (and focusing on family units)
*Creating supportive environments for women and babies
*Stopping violence against women (One example here: A study of 400 villages in rural India revealed that 16% of all deaths among pregnant women were due to partner violence. Cross-culturally, rates of violence against pregnant women are high)

One thing that this particular report didn't mention, though, was the risks that can also come along with the overmedicalization of birth. For instance, in the United States, over 30 percent of women give birth via Cesarean section. Best estimates suggest that perhaps five to ten percent of births require Cesarean intervention (and, in fact, SOWC presents similar figures). Unnecessary C-sections result in a host of risks to mothers (permanent injury to the bladder or uterus, infection, blood loss, damaged bowel functioning, future pregnancy complications, death, etc.) and babies (premature birth, breathing/lung problems, cuts and injuries, side-effects of anesthesia, difficulty breastfeeding, etc.) The United States tends to have extreme cases: On one end of the extreme are women who can't afford access to basic prenatal health care; on the other end, the trend toward non-medically-indicated elective (and expensive) C-sections that pose considerably more risk than a normal vaginal delivery.

On the child mortality list that I mentioned earlier (where the highest child death rates are closest to the top of the list), the United States comes in at number 151 out of 189; this means that there are 37 countries with lower infant-mortality rates than the United States. The countries with the best statistics (meaning the most babies who survive infancy) tend to be countries that provide a "best of both worlds" approach, where women have adequate access to prenatal care, good nutrition, supportive cultures and systems, and care providers trained in supporting natural childbirth processes, as well as emergency care. In other words, the technology exists to save mothers and babies in obstetric emergencies (and people have access to it), but low-intervention births are still considered the ideal situation for women and babies.

In case you're interested, here's the list from 151 to 189, so you can see all the countries that have better child survival rates than the U.S. The best in the world? Sweden.

United States 8 151
Cuba 7 156
Hungary 7 156
Poland 7 156
Thailand 7 156
Australia 6 160
Canada 6 160
Croatia 6 160
Estonia 6 160
New Zealand 6 160
United Kingdom 6 160
Belgium 5 166
Cyprus 5 166
Israel 5 166
Republic of Korea 5 166
Malta 5 166
Netherlands 5 166
Switzerland 5 166
Austria 4 173
Czech Republic 4 173
Denmark 4 173
Finland 4 173
France 4 173
Germany 4 173
Greece 4 173
Ireland 4 173
Italy 4 173
Japan 4 173
Monaco 4 173
Norway 4 173
Portugal 4 173
San Marino 4 173
Slovenia 4 173
Spain 4 173
Andorra 3 189
Iceland 3 189
Liechtenstein 3 189
Luxembourg 3 189
Singapore 3 189
Sweden 3 189