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Every day an average of 830 women die due to pregnancy-related causes, according to the United Nations. Most of these deaths are preventable. In more than 20 countries, Doctors Without Borders/Médecins Sans Frontières (MSF) focuses on reducing maternal and infant mortality through care during pregnancy and prenatal consultations, emergency obstetric care, postnatal care, and access to contraception and family planning services.
In 2016, MSF assisted in 250,300 births, including Caesarean sections.
The pathologies that kill women during their pregnancies, deliveries, or just after giving birth are the same throughout the world. What makes the difference is access to quality health care. The vast majority of maternal deaths, 99 percent, occur in developing countries. More than half of these deaths occur in sub-Saharan Africa, and one third in South Asia. In wealthier countries, the availability of affordable and effective treatment prevents the conditions that continue to kill pregnant women in developing settings.
Likewise, obstetric fistulas—a condition that affects women who have experienced prolonged obstructed labor—were eradicated in more developed countries at the end of the 19th century, when Cesarean section became widely available. However in poor and conflict-affected areas, women are unable to access emergency obstetric services and continue to suffer from prolonged obstetric labor which causes fistulas to occur. MSF provides treatment for fistula in some countries where obstetric services are absent, inadequate, or in need of support.
The percentage of deliveries assisted by qualified medical staff is 61 percent worldwide, but this drops to 34 percent in developing countries. In Somalia and Ethiopia, only 23 percent of deliveries involve qualified staff; in Haiti, it’s 5.6 percent. Without medical care, pregnant women are far more likely to die from obstructed labor, eclampsia, the effects of malaria, or other conditions.
In many countries and for a multitude of reasons, women deliver at home. In fact, only 40 percent of deliveries worldwide take place in medical structures. And in the countries where home-births are most common, maternal mortality is the highest.
As MSF is often the only health provider in a region, women frequently have to travel long distances to reach us, and they may not begin this journey until complications have already developed. In Ituri, for example, in eastern Democratic Republic of Congo, more than one third of the 200 deliveries taking place each month in the maternity ward of the Bon Marché Hospital present with complications such as hemorrhage or eclampsia. In many countries where MSF works, it provides care during pregnancy and prenatal consultations, emergency obstetrics, and postnatal care. MSF also helps pregnant women identify a nearby hospital so, as soon as labor begins, they know where to go.
Main Causes of Maternal Mortality
The main causes of maternal mortality are hemorrhage, sepsis, eclampsia, unsafe abortion, and obstructed labor.
Hemorrhage, or severe bleeding, accounts for a quarter of all maternal deaths. A woman, even one in good health, who hemorrhages just after giving birth can die within two hours, especially if she is left without obstetric care. Sepsis, or general infection, is the main cause of death after delivery. One in 20 women giving birth develops an infection requiring antibiotics to avoid potential fatalities. Eclampsia is the world’s third most common cause of maternal mortality. Eclampsia is linked to hypertension and is characterized by the appearance of seizures that may lead to coma and death. According to the WHO, there are approximately 70,000 cases of eclampsia each year in the 143 least-developed countries in the world. Convulsions related to eclampsia can be prevented and treated using the drug magnesium sulfate.
Unsafe abortion refers to the termination of an unintended pregnancy by persons lacking the necessary skills, in an unhygienic environment, or both. One woman dies every six minutes from unsafe abortion. Of those who live, many suffer serious consequences such as infertility, or complications with future pregnancies. Comprehensive sexual and reproductive health care services can greatly reduce the number of unsafe abortions, by offering safer alternatives through family planning and by identifying and treating complications during pregnancy early on. Obstructed labor is another leading cause of death and infirmity, particularly in sub-Saharan Africa and southeast Asia. It can also cause rupture between the vagina-bladder wall and/or the vagina-rectum wall, a condition known as obstetric fistula. Obstructed labor can be managed if it is identified early, by following a woman in labor and intervening with medication at the appropriate moment.
MSF works to remedy the 'three delays' in obstetric care that are often decisive in saving the lives of both the child and the mother. These are: the delay in deciding to seek care; the delay in reaching a health facility; and the delay in receiving adequate treatment at the facility. MSF has introduced mobile clinic that travel to areas where people often have no access to health care, combined with referral systems to identify women presenting complications and transfer them when necessary to a health post or hospital where they can receive appropriate care.
In addition to ensuring timely access to quality care, MSF also works to reduce maternal and infant mortality through provision of emergency obstetric care, as well as prenatal and postnatal care and care during pregnancy.
Emergency obstetric care administered by qualified staff, capable of handling a complicated delivery, can be a question of life or death for women experiencing complications during delivery or just after. One of MSF’s challenges can lie in encouraging the people we assist to make use of our emergency obstetric services. This requires locating services close to the people that need them, adapting the services to local cultures and making them free of charge as our beneficiaries are often among the poorest sector of the population and cannot afford to pay for health care.
Care during pregnancy and prenatal consultations improve the mother’s health during her pregnancy and encourages fetal development. The number of stillbirths is thereby reduced. In 2006, MSF teams carried out more than 450,000 prenatal consultations in various countries.
"We work on the principle that all pregnancies can be a risk," said Christine Lebrun, head of reproductive health services at MSF. "The prenatal consultations are therefore important for detecting and treating pregnant women’s health problems. We also give them health advice. The consultations provide an occasion to inform women and their families about complications that can arise during delivery, helping them prepare for emergencies and identify a health structure where they can go without delay for delivery."
Most maternal mortality and morbidity occurs after delivery. This is also a dangerous period for the child, with 30 percent of children's deaths occurring in the first four weeks of life and the majority in the first few days post-delivery. Postnatal care is important to ensure the physical and mental well-being of both the mother and child.
HIV/AIDS and Preventing Mother-To-Child Transmission (PMTCT)
Many of the places where MSF works are patriarchal societies where it is difficult for women to implement contraception in their relationships and where women are not encouraged or allowed to freely access health care. A woman's health is often a family business and she needs her husband’s permission to go to the doctor, sometimes even to receive lifesaving treatment. Without a supportive family, getting tested for and taking treatment for HIV/AIDS can be very challenging for women.
In order to reduce the stigma around the disease and encourage people to seek testing and treatment, MSF runs awareness-raising activities in many of the places where it provides HIV/AIDS care. That includes letting mothers know that it is possible to prevent their children from contracting the disease, even if they themselves are HIV-positive.
More than 90 percent of children contract HIV through the transmission of the virus from mother during pregnancy, birth, or breastfeeding. In 2009, around 370,000 children were born with HIV, bringing to an estimated 2.5 million the total number of children under 15 living with HIV, according to UNICEF. Around 90 percent of these children live in sub-Saharan Africa. Without treatment, half of children with HIV die before the age of two.
Because there is no affordable HIV diagnostic test for infants less than 18 months of age and few medicines that children can take easily, helping them is problematic. Treating children often necessitates the crushing or splitting of adult tablets, which can lead to dangerous over- or under-dosing. And bitter-tasting syrups are expensive and require refrigeration, which is difficult to come by in many African countries.
Children born to mothers living with HIV frequently contract the virus when they are breastfed, which presents a delicate situation. "It's a trade-off," says MSF medical adviser David Olson. "The risk of transmission continues, but there are risks to not breastfeeding because the mortality rate is higher. So, we are trying to get women to wean off breastfeeding earlier." Mother-to-child transmission is preventable by giving antiretroviral (ARV) drugs to HIV-positive women during their pregnancy and to the infant within a few hours of birth, and by carrying out elective cesareans and providing safe alternatives to breast milk.
Wealthy countries have been extremely successful in reducing mother-to-child transmission to below one percent. However, the transmission rate remains as high as 25 to 45 percent in poor countries. This can be attributed to the majority of mothers in poor countries not having access to diagnostic services and appropriate intervention treatments for them or their children. Even where women do have such access, the risk of transmission through breastfeeding remains.
Despite these difficulties, however, it has been shown that transmission can be reduced to around five percent, even in breastfeeding populations.
MSF is working to break the transmission chain in a number of ways. HIV/AIDS tests are offered in MSF prenatal consultation centers to identify women who are infected. Once a diagnosis has been made appropriate care can be offered to women, including ARV drugs, prenatal care, and advice on breastfeeding. After birth MSF provides preventative ARV drugs for one week to these babies, and then monitors them for infection. If, despite everything, these babies are infected, MSF will provide treatment.
At Arua Hospital in Uganda, MSF supports the PMTCT project. Up to one half of infants who contract the HIV virus from infected mothers will die by the age of two if they do not receive treatment. In 2007, MSF began rotating HIV clinic workers into the maternal-child health clinic where they can provide postnatal clinical follow-up, HIV testing, and treatment of both mothers and their babies for up to 12 months, while also acting as a link to the HIV clinic for long-term care.
MSF has called on drug companies to address the pediatric medicine problem and to produce drugs for the most vulnerable, if least wealthy, people living with HIV.
“When I was told I was HIV-positive, I was very worried. I thought; ‘How am I going to tell my husband about this? What if he tells me this is the end of our marriage? How do I present condoms to him?’ I had great fear, for me and for my unborn child.
But then I was in contact with the peer mothers. They were the ones who gave me thorough counselling. They told me, ‘You don’t have to be afraid. There’s a program that helps mothers to prevent infecting their unborn babies.’ They told me it works, so I believed them.
When I went back when my daughter was two-years old, they tested her again. ‘Your child is definitely negative,’ they told me. ‘Thank you for your great work and care of this baby.’ I was extremely happy when they told me that.”—Edna Maulana, enrolled in MSF’s prevention of mother-to-child transmission of HIV (PMTCT) program in Thyolo, Malawi
Obstetric fistulas are one of the most serious consequences of obstructed labor; a fistula can occur when the soft tissue in the pelvis is compressed by the baby’s head. The lack of blood flow causes the tissue to die, creating a hole between the vagina and bladder, the vagina and rectum, or both. The result is urinary and/or fecal incontinence. Women with fistulas live in shame and are often rejected by their own families and communities.
Worldwide, an estimated two million women have fistulas—most of them in Africa. This problem is largely hidden because it often affects young women who live in poor, remote areas with very limited or no access to maternal health care. Fistulas are largely preventable and have all but disappeared in developed countries where there is universal access to obstetric care.
The operation to close a fistula is long and delicate and requires highly specialized surgical skills. These are taught at only a few institutions in Africa. But total treatment goes beyond the surgical aspect. Because of the flow of urine and feces, affected women can develop multiple infections or skin diseases. They may also have difficulty walking and, because of their exclusion from society, they are likely to suffer from malnutrition. After surgery, in case of residual incontinence, patients often require physiotherapeutic rehabilitation. Psychosocial care is also needed in order to help reintegrate the women into their communities.
MSF doctors in most of the places where the organization works have encountered numerous women suffering from fistulas. In 2003, MSF organized its first short-term fistula camps in Ivory Coast and Chad. In subsequent years, interventions were held in Sierra Leone, Somalia, Democratic Republic of Congo (DRC), Central African Republic (CAR), and Mali. They continue today in DRC and CAR. Today, MSF also treats obstetric fistulas in Chad, and Nigeria.
Additional Threats: Malaria and Cholera
Diseases including malaria and cholera can have devastating effects on pregnant women. In many cases, contracting the illness in late stages of pregnancy can cause the mother to lose the baby. MSF treats these diseases, often with drugs proven to be harmless during pregnancy, and works to prevent transmission to the child, as well as providing psychosocial counseling for mothers who lose their babies.
In countries with high endemic malaria, such as Sierra Leone, MSF has developed a malaria program especially for pregnant women and children under five years of age.
Cherline is already dilated eight centimeters and has very high blood pressure when she arrives at the Doctors Without Borders/Médecins Sans Frontières (MSF) Centre de Référence en Urgence Obstétricales (CRUO) Hospital on October 16. She is taken immediately from the triage area to the delivery room. But her delivery stagnates, her dilation even reducing to seven centimeters. She is moved out of the delivery room to another bed.
She pushes through her labor for seven hours. It is taking a long time, and she explains to the nurse that she does not understand why. But suddenly, it happens: Cherline is brought back to the delivery room, joining two other women also in labor, and gives birth to a healthy baby girl. Her baby is taken to the examination table, wrapped up tight, and placed under warming lights. The medical staff put a yellow ointment under her eye lids to prevent eye infections that can occur during delivery.
The next day Cherline is transferred to another ward for monitoring. Clercy, her husband, visits her regularly, holding the baby with a slightly bewildered look on his face. When the baby cries, he lulls her clumsily, but she does not stop. She is hungry. Cherline breastfeeds her, but finds the first attempts are painful. The nurse gives some advice.
Cherline and Clercy decide to name their daughter Esther Clercy, and the next morning Cherline, Clercy, and Esther go home. Clercy shelters his wife and newborn daughter from the sun with two new umbrellas, still with tags on. They board a tap tap—a type of microbus. It is very crowded, but the passengers move to allow Cherline to sit in the front with Esther. They disembark at the police station, and walk under their umbrellas to a refugee camp built after the 2010 earthquake for people made homeless. It is a long walk on an unpaved road in the midday heat. Clercy takes the baby and walks a little ahead, eager to get her home: a 15 square meter shelter with metal sheeting for the walls and roof. On the right side is a bed, on the left side a small table. Their possessions are in one cupboard. Inside is even hotter than outside.
Cherline lays her baby down on the bed. She is happy to be home.