MATERNAL MORTALITY
Maternal mortality is defined as
"The death of a woman while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management."
MATERNAL MORBIDITY
Maternal Morbidity is any illness or injury caused or aggravated by, or associated with, pregnancy or childbirth.
MOST COMMON CAUSES OF MATERNAL MORBIDITY IN TEENS
Most Common Causes of Maternal Morbidity in Teens are given below
- Pregnancy-induced hypertension (PIH)
- Uterine dysfunction
- Contracted pelvis
- Premature labor
- Prolonged labor
- Cephalopelvic disproportion (CPD)
- Vaginal infection
- Vaginal laceration
- Heart disease
- Psychosocial problems
- The most consistent high risk characteristic in this
- age group is PIH
CAUSES OF MATERNAL MORTALITY
There are two kinds of causes of maternal deaths as given below:
- DIRECT CAUSES
- INDIRECT CAUSES
DIRECT CAUSES
It includes ectopic pregnancy, embolism
, anasthesia related and many more.
INDIRECT CAUSES
It includes anaemia, malaria, heart disease etc.
Source: "Maternal Health Around the World" poster. World Health Organization and the World Bank 1997.
1: Eclampsia refers to convulsions and coma occurring during pregnancy, labor or soon after childbirth. It is associated with pre-eclampsia -- a condition in pregnancy manifested by oedema (fluid retention of the ankles, hands, or face) and/or hypertension.
2: Unsafe abortion is defined as a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both. It is further example in advance.
3: Ectopic pregnancy occurs when a fertilized egg becomes implanted and begins to develop outside of the uterus usually in the fallopian tube.
4: Embolism is defined as the formation of obstructive blood clots which can be dangerous to the health.
5: Anaemia: A condition in which the blood is deficient in red blood cells, in hemoglobin, or in total volume. The most common cause of anaemia is iron deficiency. Iron deficiency occurs when an insufficient amount of iron is absorbed to meet the body's requirements. Infants, preschool children, adolescents and women of childbearing age, particularly pregnant women, are at greatest risk.
UNSAFE ABORTION – AN UNNECESSARY CAUSE OF DEATH
Unsafe abortion is defined as a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both.
(WHO)
Source: "Maternal Health Around the World" poster. World Health Organization and the World Bank 1997.
Unsafe abortion related deaths are numerous in the developing world. In countries where other causes of maternal deaths have been addressed and overall levels of maternal mortality are low, they may account for a substantial proportion of total maternal deaths.
MATERNAL DEATH CAUSES
By
MARK AGUTU
Thursday, August 5, 1999
Child birth problems kill about 4,300 women in Kenya every year, according to a document on safe motherhood trends in the country. The document, A Question of Survival: Review of Safe Motherhood, prepared for the government by two UK-based consultants, says haemorrhage, raptured uterus and complications of induced abortion account for a vast majority of these deaths. The deaths render around 11,500 children orphans every year while families of half-a-million other women are left with disabled mothers, sisters or wives suffering from life-threatening obstetric complications.
"The loss is not limited to individuals or families. It is a loss to Kenya since the women make crucial contribution to the country's social and economic development," it says.
The 40-page document was presented at a recent Reuter Foundation-sponsored workshop for medical news journalists at the Royal College of Physicians of Edinburgh, Scotland by one of the authors, Dr Wendy Graham.
Dr Graham is the director of the Dugald Baird Centre for Research on Women Health at Aberdeen University while her colleague Ms Susan Murray is from the Centre for International Child Health at the University College, London. The two say the medical causes of maternal deaths in Kenya, derived from hospital statistics show a fairly typical distribution as regards direct obstetric deaths. They blame the rising statistics on the multiple and closely interwoven determinants of maternal mortality and morbidity, but point out that malaria, anaemia, tuberculosis and HIV/Aids among other ailments also play a significant role in local maternal deaths.
"This is because majority of women in Kenya endure a lifetime of poor health and nutritional status as a direct consequence of societal, cultural, political and economic factors which discriminate against them. For the most of the women, the report asserts, it is the provision of high quality maternal care which could make the difference.
Such care should seek to avoid the deaths and maiming by preventing some obstetric complications from arising through clean and safe delivery and the effective treatment of pre-existing health problems.
The report cites, ante-natal care, clean and safe delivery, essential obstetric care and family planning as the four pillars on which safe motherhood in the country must be built.
It further suggests that the necessary planning and implementation activities should take place in unison with progress in other programme areas of reproductive health as well as with the health policy framework.
"The way forward will require the creation of an enabling environment at the policy-making level. This would enhance the quality of maternal services and their links with the community besides filling the information gap,"
The Document Recommends
Giving global trends in maternal mortality, Dr Graham told the journalists that approximately 585,000 maternal deaths occurred annually in developing countries alone.
She said the lifetime risk of dying from these causes varies significantly from about one in 1,800 in developed countries to one in 48 for the developing world. An estimated 88 per cent to ninety eight per cent of the deaths as however preventable with modest levels of health care, Dr Graham said.
The 12 journalists who attended the two-week's training on writing medical news were drawn from leading print and broadcast media organisations in selected African, Asian and East European countries.
STUDIES IN FAMILY PLANNING
RELATING TO MATERNAL MORTALITY
ABORTION IN EUROPE, 1920-91:
A PUBLIC HEALTH PERRSPECTIVE
This article grew out of a keynote address prepared for the conference,
"From Abortion to Contraception: Public Health Approaches to Reducing Unwanted Pregnancy and Abortion through Improved Family Planning Services", Held in Tbilisi, Georgia, USSR in October 1990
The article reviews the legal, religious, and medical situation of induced abortion in Europe in historical perspective, and considers access to abortion services, attitudes of health professionals, abortion incidence, morbidity and mortality, the new antiprogestins, the characteristics of abortion seekers, late abortions, post abortion psychological reactions, effects of denied abortion, and repeat abortion. Special attention is focused on the changes occurring in Romania, Albania, and the former Soviet Union, plus the effects of the new conservatism elsewhere in the formerly socialist countries of central and Eastern Europe, particularly Poland. (EUROPE, ABORTION, PUBLIC HEALTH)
A FRAMEWORK FOR ANALYZING THE DETERMINANTS OF MATERNAL MORTALITY
This article presents a comprehensive and integrated framework for analyzing the cultural, social, economic, behavioral, and biological factors that influence maternal mortality. The development of a comprehensive framework was carried out by reviewing the widely accepted frameworks that have been developed for fertility and child survival, and by reviewing the existing literature on maternal mortality, including the results of research studies and accounts of intervention programs. The principal result of this exercise is the framework itself. One of the main conclusions is that all determinants of maternal mortality must operate through a sequence of only three intermediate outcomes. These efforts must either
(1) Reduce the likelihood that a woman will become pregnant;
(2) Reduce the likelihood that a pregnant woman will experience a serious complication of pregnancy or childbirth;
(3) Improve the outcomes for women with complications. Several types of interventions are most likely to have substantial and immediate effects on maternal mortality, including family planning programs to prevent pregnancies, safe abortion services to reduce the incidence of complications, and improvements in labor and delivery services to increase the survival of women who do experience complications.
(MATERNAL MORTALITY, HEALTH PROGRAMMES)
INDUCED ABORTION IN KENYA: CASE HISTORIES
Unwanted pregnancies put women in Kenya at risk of morbidity and mortality associated with childbearing; induced abortion is an option some women seek as a response to that situation. Qualitative research was carried out to document the case histories of 30 Kenyan women who underwent induced abortion. In-depth interviews were conducted among an urban group of low-income women to identify sources of information about induced abortion and the decision-making process, and to describe the abortion experience among this group. Being unmarried and unemployed contributed to the decision to abort. Two main types of induced abortion, one provided in private facilities by medical personnel, and the other performed by a variety of untrained practitioners, are described.
MATERNAL MORTALITY IN GIZA, EGYPT: MAGNITUDE, CAUSES, AND PREVENTION
This article presents results from a population-based study of the magnitude and causes of maternal mortality in the Giza governorate of Egypt in 1985-86. Deaths to women in the reproductive ages were identified through the death registration system. Family members of the deceased were interviewed using the "verbal autopsy" approach. Immediate and underlying causes of death were then assessed by a medical panel. This methodology allows for the classification of multiple causes of death and is appropriate when registration of adult deaths is nearly complete, but reporting on cause of death on death certificates is poor. Of all reproductive-age-deaths, 19% were maternal deaths. The maternal mortality ratio for Giza is estimated to be, at minimum, 126 maternal deaths per 100,000 live births. The maternal mortality rate is estimated to be, at minimum, 22 maternal deaths per 100,000 women aged 15-49, over 100 times the rate in Sweden.
An average of 2.3 causes per maternal death were reported; the most common causes were postpartum hemorrhage (31% of cases) and hypertensive diseases of pregnancy, such as toxemia and eclampsia (28% of cases). Women experiencing hemorrhage, hypertensive diseases of pregnancy, or other serious complications must have easy access to hospital and maternity centers equipped for handling these conditions. Since most deliveries occur at home, many with the help of traditional birth attendants, TBAs will need training in early diagnosis, treatment, and/or effective referral of problem pregnancies.
(EGYPT, CONFINEMENT, MATERNAL MORTALITY)
MATERNAL MORTALITY IN NIGERIA:
THE REAL ISSUES
Kelsey A. Harrison
When the Safe Motherhood Initiative was launched in 1987, like the rest of Africa, Nigeria got deeply involved. Nobody expected miracles overnight, nor did anyone expect disasters of such immensity. Sadly, there is hard evidence to demonstrate that much of the good ideas, the good intentions, and the good work done then have failed to come to fruition. Not least is the fact that maternal mortality in sub-Saharan Africa is rising rather than falling, as it has done in all other regions of the Third World. In urban areas in Nigeria, instances abound where women are dying in the hands of good doctors just because they do not have the money to pay. In rural areas, the disaster is expanding more quickly for want of basic necessities of modern life: piped water, electric power supply, road communication, and schools for children.
High maternal mortality in Nigeria, estimated to be 1,000 per 100,000 births, will not go away as long as three fundamental issues prevail: mass poverty with gross inequalities, unbooked emergencies, and illiteracy, which bestrides and underlies both. Here, the focus is on the first two factors, as well as on structural adjustment programmes (SAPs) which, together with rampant corruption, constitute a major aggravator of poverty.
POVERTY
The contribution poverty makes to the worsening maternal health situation is best considered in a global context. Otherwise it is easy to fall into the trap of managing poverty instead of seeking to eradicate it, and of trying to cope with disasters instead of preventing them. In terms of gross national product per capita, the world's countries fall into four economic classes - rich, middle income, poor, and poorest. Between 1950 and now, GNP has increased nearly three times for the rich, 1.5 times for the middle per capita income, marginally for the poor, and none for the poorest. The gulf between the rich and the poorest has risen from eight-fold to 30-fold. There were 24 countries in the poorest group compared with 47 today, of which 29 (including Nigeria) are in sub-Saharan Africa. Africa's deepening poverty is evident in other respects, one of which is the region's increasing marginalization. With a quarter of the world's land mass and 12 percent of the world's population, Africa is rich in natural resources, yet it is only able to secure one percent of the world's trade and 0.4 percent of the world's manufacturing exports because it is technology-poor. Sixty-two percent of its population earns less than six US dollars per week; the region is therefore in a no sustainable position.
Given that Africa has the fastest growing population in the midst of so much poverty and suffering, it is easy to suppose that African women adapt well to poverty. They do not. Instead, poverty greatly amplifies every other high risk factor for maternal mortality and morbidity from grotesque female oppression to maternal under nutrition to inadequate medical and physical infrastructure. The consequences are stark. Singapore and Nigeria were peers in the 1960s. Currently, Singapore's GDP per capita is 16,621 US dollars, its maternal mortality ratio is 10 per 100,000 births, and the lifetime risk of dying in pregnancy is 1 in 4,900. The equivalent figures for Nigeria are 256 US dollars, 1,000 per 100,000 births, and a lifetime risk of 1 in 13.1. A 66-fold difference in GDP per capita manifests as a nearly 400-fold difference in maternal death. The point is that poverty, when combined with gross inequality, ranks as the major killer.
UNBOOKED EMERGENCIES
Unbooked emergencies constitute the main high-risk group for maternal mortality in Nigeria, making up no fewer than 70 percent of all hospital maternal deaths in the country.2,3 These women fail to receive antenatal care and instead arrive at hospital for the first time when life is already endangered by difficult labour, advanced pregnancy complications, or coincidental disease. The late arrival is due to various constraints - cultural, financial, social, transportation, telecommunication barriers, and most importantly, illiteracy. More recently, the activities of rapidly growing but controversial evangelistic Protestant churches add hugely to the problem. It is true that they help people cope with the stresses of every day life, but they also drive women away from orthodox maternity care.
The unbooked emergencies as a group suffer the consequences of antenatal neglect (no malaria prophylaxis, unchecked hypertensive complications, anaemia), neglect in labour leading to obstruction, uterine rupture, obstetric fistula and foetal death, and postpartum neglect leading to blood loss and infection.
The delay in seeking orthodox health care leads to a number of co-morbidity patterns. Often disease is very advanced, to the point that two or more complications are nearly always present in each woman affected. It is common for very severe anaemia and bacterial infections including active pulmonary tuberculosis to co-exist with conditions requiring emergency operations such as retained placenta, obstructed labour, and antepartum haemorrhage. Hence unbooked emergencies become poor anaesthetic and operative risks, with attendant huge increases in mortality and morbidity rates. For most of the survivors, recovery is slow, hospital stay is prolonged, and treatment costs increase. As a result, scarce resources are concentrated on attempts to salvage moribund women so the rest get less than their due. Additionally, the babies of unbooked emergencies fare poorly.
STRUCTURAL ADJUSTMENT PROGRAMMES (SAP)
Earlier it was stated that sub-Saharan Africa is the only region in the developing world that has experienced worsening maternal health standards in the last decade. SAP is largely to blame, although it is by no means the only factor. Africa was doing well in the immediate post-colonial period, until economic decline worsened in the mid-1980s through deepening recession, falls in commodity prices, rise in indebtedness levels, and large-scale financial corruption. The World Bank and the International Monetary Fund stepped in to restore fiscal discipline through a set of macroeconomic policies designated as SAPs.The aims of SAP were debt recovery in the short term and poverty reduction through economic growth in the long term. The doctrines of SAP are: worker retrenchment, removal of subsidies, currency devaluation, trade liberalization, and privatization of public utilities.
In most areas in sub-Saharan Africa restructuring promoted dangerous inequality, social upset, and disintegration of all forms of infrastructure built in the 1960s and 1970s. School enrolment that showed a spectacular rise in the 1970s has fallen since the mid-1980s and drop-out rates have soared. The attempt at debt control has collapsed: currently sub-Saharan Africa's total debt as percentage of GNP exceeds 110 percent compared with around 30 percent in 1980. A free market system that is highly prejudicial against social welfare is being established before Africa is ready: good infrastructure, competent management and administrative capability, high literacy levels, and good information systems are all necessary to make SAP work, but they are lacking in Africa. The result is misery all round, with the most telling effects on education and maternal and child health. Concerning reproductive health, high hospital user fees have deterred at-risk women from booking for orthodox health care, and as a result more life-endangering emergencies are being admitted without having proper care. Frequent and prolonged periods of industrial action have also contributed to the problem, but the charging of user fees is much more important.
At the same time, other unfavorable characteristics of reproduction in Nigeria continue unabated: early marriage, early teenage pregnancy, low contraceptive usage, high fertility, and huge fatalities from induced and unsafe illegal abortions. With increasing financial hardships and social dislocation, prostitution increases as does the spread of sexually transmitted diseases, even among adolescents.
POSSIBLE SOLUTIONS
Relevant knowledge on the achievement of drastic maternal mortality reduction in poor countries is not lacking. China, Cuba, Costa Rica, Sri Lanka, and the state of Kerala in India have all done this. In each case, strong political will created the right priorities, made literacy and contraceptive use widespread, and established equity in health care usage including antenatal and intrapartum care. These actions, properly coordinated, are not beyond us in Nigeria, but this has barely started. For now, the stage is set for us to organize and establish proper referral systems linking all three tiers of health care (primary, secondary or first referral level, and tertiary). Exempting pregnant women from user fees is absolutely vital. Attempts to establish these things in the present economic climate is a daunting prospect, but it is well within our capability.
CONCLUSION
High maternal mortality is a manifestation of gross underdevelopment. Hence, its permanent reduction requires societal transformation. Everywhere, the fundamental requirements are a determined leadership able to put organization, discipline, and mass education of good quality into place. Additionally in Nigeria, the current focus should be directed towards the unbooked emergencies, the principal high risk group for maternal mortality. The provision and use of life-saving treatment is paramount, but at the same time efforts towards eliminating the conditions which create the unbooked emergencies must persist. Expert prioritization of the action plans and their implementation and careful avoidance of misapplication are essential.
MATERNAL HEALTH AROUND THE WORLD
Lifetime risk of maternal death
The risk of an individual woman dying from pregnancy or childbirth during her lifetime, Calculations based on maternal mortality and fertility rate in a country. A lifetime risk of 1 in 3000 represents a low risk of dying from pregnancy and childbirth, while 1 in 100 is a high risk.
Skilled attendant at delivery
Percentage of deliveries attended by skilled persons(doctor, midwife, nurse).
Prenatal deaths per 1000 births
Stillbirths and deaths in the first week of life
Country | Lifetime risk of maternal death 1 woman in: | Skilled attendant at delivery (%) | Prenatal deaths per 1000 births |
7 | 8 | 120 | |
Albania | 430 | 99 | 15 |
Algeria | 120 | 77 | 25 |
Niger | 9 | 16 | 100 |
60 | 92 | 30 | |
38 | 18 | 70 | |
India | 37 | 35 | 65 |
Indonesia | 41 | 36 | 45 |
Iran (Islamic Rep. of) | 130 | 74 | 30 |
Iraq | 46 | 54 | 40 |
Ireland | 3800 | 99 | 10 |
Israel | 4000 | 99 | 10 |
Italy | 5300 | 100 | 10 |
280 | 92 | 40 | |
Japan | 2900 | 100 | 5 |
Source: "Maternal Health Around the World" poster. World Health Organization and the World Bank 1997.
FACTORS INFLUENCING MATERNAL MORTALITY IN BANGLADESH FROM A GENDER PERSPECTIVE
Debashish Kumar Dey, MBBS, MPH
Department of Geriatric Medicine, Göteborg University, Vasa Hospital, S-411 33, Göteborg, Sweden.
This paper was written as a project work during the course on "Public health from a gender perspective", Spring, 1998, in the Dept. of Family Medicine, Umea University, Sweden.
ABSTRACT
Gender differences in health in developing countries have, until recently, received little attention from researchers, health programmers and international development efforts. Gender is a socially constructed difference between men and women. Maternal mortality is a particularly sensitive indicator of inequity, it display the status of women, their access to health care system in responding to their needs. The cause of a maternal death often has some roots in a woman's life. A major barrier for women to the achievement of the highest attainable standard of health is inequality, both between men and women and among women in different geographical regions, social classes and indigenous and ethnic groups.
The biological aspects to women's health are vastly influenced by the socio-economic and cultural context. Maternal mortality should not be viewed as a chance event so much as a chronic disease developing over a long period, for the outcome of a pregnancy is profoundly influenced by the lower status and circumstances of a woman's life i.e. inadequate access to nutrition and health care in childhood, illiteracy and heavy burdens of domestic work all have damaging effects on women's general health, and therefore on their potential for healthy childbearing. In Bangladesh, due to patriarchy, traditionally the men are superior to the women. It is reinforced by various institutions - religious, economic, political, social and legal - all of which emphasize women's inferior position in the society. All these have implications for women's health status and health behavior in the event of illness.
The obstacles which lead to maternal deaths in Bangladesh do not relate only to deficiencies in health care; they are largely social, cultural and economic. Many of these factors are intertwined with gender inequality, reflected in women's lower status in the society. An estimated 60,000 women of reproductive age die every year in Bangladesh.
Most of them are resulted from poor socio-economic conditions, son preference, utilization of health care facilities, barriers in decision making, reaching and receiving treatment and the disadvantaged status of women , the latter responsible for limited access of women to key resources such as food and health care. Maternal mortality can not be reduced unless women have timely access to the health care facilities and to achieve this, greater emphasis should be given to improve the status of women in the society in order to increase their capacity to control their lives, including their sexual and reproductive health.
Key words: Maternal mortality, maternal morbidity, women's health, gender, women's reproductive health, safe motherhood, developing countries, Bangladesh.
INTRODUCTION
Gender differences in health in developing countries have, until recently, received little attention from researchers, health programmers and international development efforts. Even in the industrialized world, women's issues were not part of the overall health care agenda prior to the 1980s. Maternal mortality is a particularly sensitive indicator of inequity, it display the status of women, their access to health care system in responding to their needs. Levels of maternal mortality in industrialized and low income countries show a greater disparity than any other public health indicator.
In Bangladesh, maternal mortality ratio is very high and is a major public health problem, not only due to the large number of such deaths, but, also due to the traumatic aftereffect of such an event on the family in particular and society in general.
Among the indicators of the health of community - mortality, morbidity, and malnutrition - mortality is the most commonly employed. Unlike morbidity and malnutrition, which are difficult to define and quantify, mortality can be readily identified. The level and pattern of maternal mortality are important
indicators of the status of maternal health.
A major barrier for women to the achievement of the highest attainable standard of health is inequality, both between men and women and among women in different geographical regions, social classes and indigenous and ethnic groups.
Gender is a socially constructed difference between men and women. The difference between sex and gender is that, gender is social and cultural in nature rather than biological. In most societies, gender predetermines different expectations about the appearance, qualities, behaviour and work appropriate for male or female. The social relations of gender are not determined by biological differences, however biological differences play role in social relation of gender.
The three concepts of gender inequality are inequality in prestige, power and access to control resources. The concept of gender enables us to explain why women's health has received so little attention. Women traditionally have held a lower socioeconomic status and been seen dependent upon men. Women's lower status influences their health in many ways. Because of reduced access to education and information, they are often poorly informed about their health. This results in failure to recognise early symptoms of infection and disease, leading to chronic health problems.
"Women's lower status in the family, where decisions regarding mobility and expenditures for health care are in the hands of men, it is not so easy for them to seek health care. It has also been widely recognised that women are treated in an inferior way by health care providers, and that they are therefore hesitant to seek treatment"
The biological aspects to women's health are influenced by the socio-economic and cultural context. There are various different ways in which the health risks faced by women are influenced by gender - by the socio-economic and cultural aspects of being female.
.
Maternal mortality should not be viewed as a chance event so much as a chronic disease developing over a long period, for the outcome of a pregnancy is profoundly influenced by the lower status and circumstances of a woman's life
(WHO 1989)
Inadequate access to nutrition and health care in childhood, illiteracy and heavy burdens of domestic work all have damaging effects on women's general health, and therefore on their potential for healthy childbearing. These lifelong disadvantages are compounded by cultural and economic pressures towards early marriage and pregnancy.
BACKGROUND: BANGLADESH STATUS OF WOMEN IN BANGLADESHI SOCIETY
The society of Bangladesh is patriarchal; traditionally the men are superior to the women. The patriarchal structure of the societies in the third world countries prescribes an inferior or subordinate status for women in the society. It is reinforced by various institutions - religious, economic, political, social and legal - all of which emphasize women's inferior position in the society. Thus women are expected to be subordinate to men within and outside the household. Women's access to material resources were restricted, leaving them dependent on male relatives. All these have implications for women's health status and health behaviour in the event of illness. Women in Bangladesh suffers extensive discrimination, being generally regarded as useful only for sex, reproduction, and housework. Although the constitution provides equal right for both sexes, the existing social norms and practices do not allow them to utilise it properly. In matters of marriage, divorce, maintenance and inheritance, women are deprived of equal rights. Violence against women within the family is not considered as a violation of women's basic dignity and human rights. Women are frequently deprived of their human right to self determination. In Bangladesh, both Muslim (86% of total population) and Hindu (12%) religions restricted the autonomy of women in different ways. Muslim women are subjected to the rules of Purdah (seclusion), which limits their mobility and education. Hindu women enjoy comparatively greater mobility, but they too are subject to prejudice and restrictions.
MATERNAL MORTALITY IN BANGLADESH
In Bangladesh, the maternal mortality ratio is 420 per 100,000 live births. However, several population based studies on maternal mortality shows different mortality ratios varying from 440 to 770 per 100,000 live births. The common causes of maternal deaths include postpartum haemorrhage, pregnancy induced hypertension/pre-eclampsia/eclampsia, complications of abortion, obstructed/prolonged labour, concommitent causes and other obstetric causes.
WOMEN'S ACCESS TO HEALTH CARE FACILITIES
In Bangladesh, most of the mothers are not utilizing them mainly due to socio- cultural barriers. Around 12-74 percent of all pregnant women receive antenatal care in Bangladesh. About 98 percent of deliveries take place in homes and only 2 percent in institutions. About 9 percent of all births take place in the hands of trained providers. The majority of the deliveries receive some interventions, mostly non-medical interventions or drugs and injections given by medical staff, paramedics as well as traditional practitioners. Women's status affects women's access to health services by directly affecting the decision to seek care.
AIMS
The aim of this paper is to describe the prevailing situation of maternal mortality in Bangladesh through review of published literature and focus on the factors influencing maternal deaths from a gender perspective.
MATERIAL AND METHODS
The method used was a literature review where published articles on Maternal mortality in Bangladesh were analysed from a gender perspective. The literature was identified from national and international journals, official publications of government and non-governmental organisations of Bangladesh, publications from international health organisations.
RESULTS AND DISCUSSION
There exists scarcity in published scientific papers on maternal mortality in Bangladesh. Few studies have been conducted in this field and most of them are from a defined demographic area. Levels and patterns of maternal mortality in different studies are similar. In the analysis of the relative risks of specific socio-demographic characteristics, such as age, parity, birth interval, gender disparity, women's status in the society, their access to health care and the cumulative effect of these socio-cultural variables on maternal mortality were not addressed in any one of these studies. Constrained resources and difficult field conditions often imposed limitations on the scope and nature of the research and on the methodologies used (Maternal health 1995).
CAUSES OF MATERNAL MORTALITY
In a study from Matlab demographic surveillance system (a rural area about 60km from Dhaka, the capital of Bangladesh) it was identified that a total of 1037 women of reproductive age died during the 10 year period (1976-85) and 37 percent of them were maternal deaths (Fauveau et al 1988). Table 1 shows the distribution of cause of maternal deaths. Over three-quarters of all maternal deaths were from direct obstetric complications and it needs timely and adequate medical intervention.
Table 1 - Causes of Maternal death in rural Bangladesh, 1976-85 (n=387)
| Cause of death | Percentage of death |
Direct obstetric | Postpartum haemorrhage | 19.8% |
| Abortion | 18.2% |
| Pre-eclampsia/Eclampsia | 12.0% |
| Sepsis | 6.8% |
| Obstructed labour | 6.5% |
| Other obstetric | 14.0% |
Concomitant | Injuries, violence | 9.1% |
| Medical causes | 9.1% |
Unspecified | Unspecified | 5.2% |
Total |
| 100% |
Source : Fauveau et al 1988
Abortion is a leading cause for maternal death in Bangladesh. It has been estimated about one-sixth of the total maternal deaths in a study in rural Bangladesh (Alauddin 1986). Signs of sepsis accompanied 85 percent of all abortions. Unmarried women accounted for 36 percent of all complications of induced abortion (Fauveau et al 1988). The risks for unmarried women are much greater than married women. Septic abortion is more common in teenaged unmarried women and such deaths are far less reported as parents and relatives tend to hide the cause of death of an unmarried daughter following an induced abortion. Pregnancy out of wedlock is socially unacceptable and there is no sympathy from the community if it ends in death.
Percentage of maternal deaths from eclampsia varies from 12 to 53 percent in different studies. The proportion of deaths caused by eclampsia decreases with age (Fauveau et al 1988). The findings are consistent with the results of other developing countries. Haemorrhage comprises 20 percent of all direct obstetric deaths. Death due to obstructed labour comprises complications of malpresentation, cephalopelvic disproportion, and inability to expel the fetus (Fauveau et al 1988). In another study, Khan et al has found that difficulties with the process of delivery (obstructed labour and retained placenta) accounts for 17 percent of total maternal death. Sepsis continues to be one of the major causes of maternal death; more than one-fourth of all maternal deaths in a study from rural Bangladesh were caused by sepsis, mostly arising from complications of improperly performed abortion.
In their study in Matlab area, Fauveau et al found 77 percent of fatal injuries and violent deaths occurred during pregnancy. The percentage of maternal death due to injuries and violence might be under reported in this study. These deaths are not clearly obstetric in nature, but they were more common in the study area. The lack of personal autonomy and bargaining power within relationships puts women at risk of physical and sexual violence and limit their ability to negotiate sexual practices and contraceptive choices.
"The underlying causes of violent deaths among women of reproductive age, i.e. complications of an induced abortion, suicide and homicide, are clearly social. Many of them may be seen as a consequence of the strict control enforced by males over the sexual life of women and reproduction"
FACTORS INFLUENCING MATERNAL MORTALITY FROM A GENDER PERSPECTIVE
After reviewing the literature, it was found that, the obstacles which lead to maternal deaths in Bangladesh do not relate only to deficiencies in health care; they are largely social, cultural and economic. Many of these factors are interwined with gender inequality, reflected in women's lower status in the society. An estimated 60,000 women of reproductive age die every year in Bangladesh. Most of them are resulted from poor socio-economic conditions, high fertility and the disadvantaged status of women , the latter responsible for limited access of women to key resources such as food and health care. The social and cultural factors which has vast influence on women in their health status and access to health care services include:
- socio-economic status of women
- son preference
- utilization of health care facilities
- barriers in decision making, reaching and receiving treatment
SOCIO-ECONOMIC STATUS
Women's vulnerability rise from the physical environment where they live, their employment status and numbers of other factors. In the majority, origins of women's vulnerability are well established in factors related to gender
(WHO 1992)
One of the most important factors which affects the maternal mortality in Bangladesh is low social status of women. Their needs of health, education and employment are given the lowest priority. Women are married at a young age and undergo the trails of constant motherhood, besides the drudgery of household chores. In Bangladesh, one girl in five fails to enjoy her fifth birthday. One 15 year old girl out of six will not survive her childbearing years. The calorie intake of adult women is 29% less than adult men. Two thirds of school age girls are not in school, and female university enrolment is less than 4%. Life expectancy at birth is 55 years for men and 54 years for women, one year less than the average man. 7% of Bangladeshi women work for pay, comprising only 14% of the formal labor force. The status of girls and women in society, and how they are treated or mistreated, is a crucial determinant of their reproductive health. Educational opportunities for girl and women powerfully affect their status and the control they have over their own lives, their health and fertility. The empowerment of women is therefore an essential element for health
(WHO 1996)
SON PREFERENCE
The literature on excess female mortality has shown that son preference discriminated the family allocation of food and the access to health care services for girls in Bangladesh.
Reasons given for families preferring sons to daughters include:
- sons maintain and extend the lineage;
- sons inherit family property;
- they act as a hedge against financial disaster;
- they provide support for parents in old age;
- they farm the family land.
Daughters on the other hand are considered as a liability for the family, because:
- they marry early and outside the family, any investment in them is lost to the family;
- they contribute little to household expenses;
- they require large dowries and expensive weddings;
- they provide no support to the family of origin after marriage.
For these reasons, families preferred to have sons and to maintain them in good health since sons are considered as an asset for the family. In Bangladesh, women, on average, continue to bear children for 23-25 years between first and last birth of their child and "strong son preference" plays a significant role for this.
UTILISATION OF HEALTH CARE FACILITIES
Utilization of health services is a complex phenomenon which is affected by factors such as availability, distance, cost, quality of care, social structure and health beliefs. Approximately 75% of the women, who die from a pregnancy-related complication, die at home without any professional assistance. A study regarding utilization of antenatal care shows among all respondents 14.8% never had antenatal care during their last pregnancy. Over 42% reported two visits and 20% reported three visits whereas, only 2.3 percent reported four visit. Only 9% deliveries are conducted by trained personnels.
"Women's access to health care is also influenced by restrictions on mobility and seclusion of women in the household. Costs and distance considerations are also inter-related with gender inequality. Furthermore, gender inequality in access to health care is reflected in women's unwillingness to go to hospital to deliver because it will disrupt household organization, there may be none to take care of older children or their husbands"
The feelings of the majority of the women have been reflected by these words
"We always try to deliver at home," and "It is better to be at home, because, I can supervise the housework…." Besides, "at the hospital, I need to spend money"
Poor service delivery systems in the health care facilities also feared women to receive it.
"Sometimes maternal deaths are due to inadequate care on arrival in hospital"
Complaints about poor quality of care can be visualized through the comment of a woman with obstetric complication.
"There wasn't anyone to take care of me. Ayahs (helpers) do most of the work. I thought that if I gave money to the nurses, then they would assist" and "When you call them (the nurses and helpers), they ignore you. The doctors are good. The others are most uncooperative."
BARRIERS IN DECISION-MAKING, REACHING AND RECEIVING HEALTH CARE
Maternal deaths can be avoided significantly if women have access to emergency obstetric care. To obtain obstetric care, women with obstetric complications face a variety of barriers. Some of these barriers are cultural e.g. the low value places on women's lives. Some of the barriers are geographic e.g. long distance and poor communication, some are economic e.g. lack of money to pay for transport and there are some socio-cultural barriers which causes these delays. The problem is not solely medical. Gender inequality affects women's timely use of health services. The subordinate status of women in society limits their autonomy in decision-making, it limits their access to transportation, and leads to discrimination in health care utilization.
As the women don't have autonomy and economic power, they don't have any influence on their families to make a decision in favor of her. Studies show that, though their situations are critical and they need emergency obstetric care, several women were refused to be referred to hospitals with such facilities because their husband was absent or the husband did not give permission for referral. Most women realize the life danger for themselves or for the child, but the family members did not perceive such danger.
The gender inequality, roles of the health system and the community can be easily visualized using the
"Three delays" model (Figure 1 in next page).
Figure - 1 The Three Delay Model
CONCLUSION
One of the root causes is that often proper value is not put on a woman's life, consequently not enough effort is made to treat her problems. Moreover, many women are subject to abuse and sexualized violence at home, and face negligence in health care facilities. Hence, taking steps to enhance the status of women through education and economic empowerment in society will be more effective to reduce maternal mortality. Greater emphasis should be given to improving the status of women in the society in order to increase their capacity to control their lives, including their sexual and reproductive health. There should be a drive in mobilizing the health infra-structure to ensure the utilization at the optimum level. Applying a gender perspective to health policy and services it needs to take account of the broader socio-economic and cultural context that shapes positions and actions of women and men. Maternal mortality can not be reduced unless women have access to the health care facilities. Besides, strategies should be taken in both government and non-government levels focusing female education, empowerment of women, the prevention of teenage pregnancy and early marriage, reduction of gender disparity, improvement of public awareness and disseminating information about danger signs during pregnancy and delivery. This should be developed as a social movement through concerted efforts by all rather than a beneficiary focused approach.
