《卫生经济学》课程参考文献（WHO年度报告）：World Health Report 2005_Make every mother and child count_Chapter4 attending to 136 million births, every year

chapter four attending to 136 million births, every year For both mother and baby childbirth can be the most dangerous moment in life. This chapter examines the main complications of childbirth, which claim an estimated 529 000 maternal deaths per year-almost all of them in developing countries. Most of the deaths and disabilities attributable to childbirth are avoidable, because the medical solutions are well known immediate and effective professional care during and after labour and delivery can make the difference between life and death for both women and their newborns. each and every mother and each and every newborn needs skilled maternal and neonatal care provided by professionals at and after birth-care that is close to where and how people live, close to their birthing culture, but at the same time safe, with a skilled professional able to act immediately when largely unpredictable complications occur. The challenge that remains is therefore not technological but strategic and organizationa RISKING DEATH TO GIVE LIFE well known. The challenge that remains is therefore not For anyone who has been through the experience, or seen technological, but strategic and organizational else go through it, there is no doubt that childbirth is a life-ch Maternal mortality is currently estimated at 529 000 event. Unfortunately, as wonderful and joyful experience as deaths per year( 2), a global ratio of 400 maternal many, it can also be a difficult period, bringing with it new problems deaths per 100 000 live births. Where nothing is done as well as the potential for suffering In the most extreme cases the to avert maternal death, "natural"mortality is around mother, or the baby, or both, may die; these deaths are only the tip of 1000-1500 per 100 000 births, an estimate based on the iceberg Many health problems are laid down in the critical hours historical studies and data from contemporary reli of childbirth- both for mother and for child. Many more continue to gious groups who do not intervene in childbirth (3) unfold in the days and weeks after the birth the suffering related to women were still experiencing "natural"maternal mor- childbirth adds up to a significant portion of the world s overall tally tality rates today -if health services were discontin of ill-health and death(1). Most of the deaths and disabilities attrib- ued, for example- then the maternal death toll would utable to childbirth are avoidable because the medical solutions are be four times its current size, totalling over two million

61 chapter four attending to 136 million births, every year RISKING DEATH TO GIVE LIFE For anyone who has been through the experience, or seen someone else go through it, there is no doubt that childbirth is a life-changing event. Unfortunately, as wonderful and joyful experience as it is for many, it can also be a difficult period, bringing with it new problems as well as the potential for suffering. In the most extreme cases the mother, or the baby, or both, may die; these deaths are only the tip of the iceberg. Many health problems are laid down in the critical hours of childbirth – both for mother and for child. Many more continue to unfold in the days and weeks after the birth. The suffering related to childbirth adds up to a significant portion of the world’s overall tally of ill-health and death (1). Most of the deaths and disabilities attrib￾utable to childbirth are avoidable, because the medical solutions are well known. The challenge that remains is therefore not technological, but strategic and organizational. Maternal mortality is currently estimated at 529 000 deaths per year (2), a global ratio of 400 maternal deaths per 100 000 live births. Where nothing is done to avert maternal death, “natural” mortality is around 1000–1500 per 100 000 births, an estimate based on historical studies and data from contemporary reli￾gious groups who do not intervene in childbirth (3). If women were still experiencing “natural” maternal mor￾tality rates today – if health services were discontin￾ued, for example – then the maternal death toll would be four times its current size, totalling over two million For both mother and baby, childbirth can be the most dangerous moment in life. This chapter examines the main complications of childbirth, which claim an estimated 529 000 maternal deaths per year – almost all of them in developing countries. Most of the deaths and disabilities attributable to childbirth are avoidable, because the medical solutions are well known. Immediate and effective professional care during and after labour and delivery can make the difference between life and death for both women and their newborns. Each and every mother and each and every newborn needs skilled maternal and neonatal care provided by professionals at and after birth – care that is close to where and how people live, close to their birthing culture, but at the same time safe, with a skilled professional able to act immediately when largely unpredictable complications occur. The challenge that remains is therefore not technological, but strategic and organizational

62 The World Health Report 2005 maternal deaths per year worldwide. The truth is that three quarters of these deaths are currently avoided throughout the world: nearly all the"natural "maternal mortality in developed countries, but only two thirds in the South-East Asia and Eastern Medi- terranean Regions and only one third in African countries There are immense variations in death rates in different parts of the world. Maternal deaths are even more inequitably spread than newborn or child deaths. a tiny 1% of maternal deaths occur in the developed world. Maternal mortality ratios range from 830 per 100 000 births in African countries to 24 per 100 000 births in European countries. Of the 20 countries with the highest maternal mortality ratios, 19 are in sub-Saharan Africa. Regional rates mask very large disparities between countries. Re gions with low overall mortality rates, such as the European Region, contain countries with high rates. Within one single country there can be striking differences between subgroups of the population. Rural populations suffer higher mortality than urban dwellers, rates can vary widely by ethnicity or by wealth status, and remote areas bear a heavy Maternal deaths are deaths from pregnancy-related complications occurring through out pregnancy, labour, childbirth and in the postpartum period (up to the 42nd day after the birth). Such deaths often occur suddenly and unpredictably. Between 11% and 17% of maternal deaths happen during childbirth itself and between 50% and 71% in the postpartum period(4-8). The fact that a high level of risk is concentrated during childbirth itself, and that many postpartum deaths are also a result of what hap- pened during birth, focuses attention on the hours and sometimes days that are spent in labour and giving birth, the critical hours when a joyful event can suddenly turn into an unforeseen crisis. The postpartum period- despite its heavy toll of deaths-is often neglected (4, 9). Within this pe Figure 4.1 Causes of maternal death riod, the first week is the most prone to risk. About 45%of postpartum maternal deaths occur during the first 24 hours Severe bleeding and more than two thirds during the first Indirect causes week(4 The global toll of postpartum maternal deaths is accompanied by the great and often overlooked number of early newborn deaths and stillbirths. Maternal deaths result from a wide range of indirect and direct causes. Other direct causes represent 20% of the global total. They are caused by diseases (pre-existing or concurrent) that are not complications of pregnancy, but complicate pregnancy Infections or are aggravated by it. These include malaria, anaemia. HiviaiDs and cardio vascular disease. Their role in maternal mortality varies from country to country, according to the epidemiological context obstructed and the health systems effectiveness in The lion s share of maternal deaths Total is more than 100% due to rounding is attributable to direct causes. Direct

62 The World Health Report 2005 maternal deaths per year worldwide. The truth is that three quarters of these deaths are currently avoided throughout the world: nearly all the “natural” maternal mortality in developed countries, but only two thirds in the South-East Asia and Eastern Medi￾terranean Regions and only one third in African countries. There are immense variations in death rates in different parts of the world. Maternal deaths are even more inequitably spread than newborn or child deaths. A tiny 1% of maternal deaths occur in the developed world. Maternal mortality ratios range from 830 per 100 000 births in African countries to 24 per 100 000 births in European countries. Of the 20 countries with the highest maternal mortality ratios, 19 are in sub-Saharan Africa. Regional rates mask very large disparities between countries. Re￾gions with low overall mortality rates, such as the European Region, contain countries with high rates. Within one single country there can be striking differences between subgroups of the population. Rural populations suffer higher mortality than urban dwellers, rates can vary widely by ethnicity or by wealth status, and remote areas bear a heavy burden of deaths. Maternal deaths are deaths from pregnancy-related complications occurring through￾out pregnancy, labour, childbirth and in the postpartum period (up to the 42nd day after the birth). Such deaths often occur suddenly and unpredictably. Between 11% and 17% of maternal deaths happen during childbirth itself and between 50% and 71% in the postpartum period (4–8 ). The fact that a high level of risk is concentrated during childbirth itself, and that many postpartum deaths are also a result of what hap￾pened during birth, focuses attention on the hours and sometimes days that are spent in labour and giving birth, the critical hours when a joyful event can suddenly turn into an unforeseen crisis. The postpartum period – despite its heavy toll of deaths – is often neglected (4, 9). Within this pe￾riod, the first week is the most prone to risk. About 45% of postpartum maternal deaths occur during the first 24 hours, and more than two thirds during the first week (4). The global toll of postpartum maternal deaths is accompanied by the great and often overlooked number of early newborn deaths and stillbirths. Maternal deaths result from a wide range of indirect and direct causes. Maternal deaths due to indirect causes represent 20% of the global total. They are caused by diseases (pre-existing or concurrent) that are not complications of pregnancy, but complicate pregnancy or are aggravated by it. These include malaria, anaemia, HIV/AIDS and cardio￾vascular disease. Their role in maternal mortality varies from country to country, according to the epidemiological context and the health system’s effectiveness in responding (10). The lion’s share of maternal deaths is attributable to direct causes. Direct Severe bleeding (haemorrhage) 25% Infections 15% Eclampsia 12% Obstructed labour 8% Unsafe abortion 13% Indirect causes 20% Other direct causes 8% a Total is more than 100% due to rounding. Figure 4.1 Causes of maternal deatha

attending to 136 million births, every year 63 maternal deaths follow complications of pregnancy and childbirth, or are caused by any interventions, omissions, incorrect treatment or events that result from these complications, including complications from(unsafe)abortion. The four other major direct causes are haemorrhage, infection, eclampsia and obstructed labour (see Fig ure 4.1). The levels of matemal mortality depend on whether these complications are dealt with adequately and in a timely manner(10) he most common cause of maternal death is severe bleeding, a major cause of death in both developing and developed countries (11, 12 ). Postpartum bleeding can kill even a healthy woman within two hours, if unattended. It is the quickest of mater nal killers. An injection of oxytocin given immediately after childbirth is very effective in reducing the risk of bleeding. In some cases a fairly simple-but urgent- interven- tion such as manual removal of the placenta may solve the problem. Other women may need a surgical intervention or a blood transfusion, both of which require hospitaliza tion with appropriate staff, equipment and supplies. The proportion needing hospital care depends, to some extent, on the quality of the first-level care provided to women for example, active management of the third stage of labour reduces postpartum bleeding. The proportion that dies depends on whether appropriate care is provided apidly. The situation with regard to postpartum bleeding could improve if the promis- ing potentialities of the drug misoprostil are realized. Misoprostil is less effective than oxytocin, but it is cheaper, easier to store safely and does not require an injection. Therefore it remains attractive where women do not have access to professional care at birth. If further research can demonstrate its effectiveness in the many cases where oxytocin is not an option, misoprostil could save many lives and reduce the number of women who suffer anaemia as a result of a postpartum haemorrhage - currently 1.6 million every year. The second most frequent direct cause of death is sepsis, responsible for most late postpartum deaths. During the 19th century puerperal sepsis took on epidemic propor- tions, particularly in lying-in hospitals. The introduction of aseptic techniques brought a spectacular reduction of its importance in the developed word (13). However, sepsis is still a significant threat in many developing countries. One out of 20 women giving Table 4.1 Incidence of major complications of childbirth, worldwide Number Case-fatality Main sequelae DALYs lost (%0f of cases r survivors (000) live births) per year Postpartum 10.5 13 795 000 1 132 000 Severe anaemia 4 418 haemorrhage Sepsis 4.4 5768000 1.3 79000 Infertility Pre-eclampsia 4152000 63000 Not well evaluated 2 231 and eclampsia Obstructed labour 4.6 6038000 0.7 42000 incontinence

attending to 136 million births, every year 63 maternal deaths follow complications of pregnancy and childbirth, or are caused by any interventions, omissions, incorrect treatment or events that result from these complications, including complications from (unsafe) abortion. The four other major direct causes are haemorrhage, infection, eclampsia and obstructed labour (see Fig￾ure 4.1). The levels of maternal mortality depend on whether these complications are dealt with adequately and in a timely manner (10). The most common cause of maternal death is severe bleeding, a major cause of death in both developing and developed countries (11, 12). Postpartum bleeding can kill even a healthy woman within two hours, if unattended. It is the quickest of mater￾nal killers. An injection of oxytocin given immediately after childbirth is very effective in reducing the risk of bleeding. In some cases a fairly simple – but urgent – interven￾tion such as manual removal of the placenta may solve the problem. Other women may need a surgical intervention or a blood transfusion, both of which require hospitaliza￾tion with appropriate staff, equipment and supplies. The proportion needing hospital care depends, to some extent, on the quality of the first-level care provided to women; for example, active management of the third stage of labour reduces postpartum bleeding. The proportion that dies depends on whether appropriate care is provided rapidly. The situation with regard to postpartum bleeding could improve if the promis￾ing potentialities of the drug misoprostil are realized. Misoprostil is less effective than oxytocin, but it is cheaper, easier to store safely and does not require an injection. Therefore it remains attractive where women do not have access to professional care at birth. If further research can demonstrate its effectiveness in the many cases where oxytocin is not an option, misoprostil could save many lives and reduce the number of women who suffer anaemia as a result of a postpartum haemorrhage – currently 1.6 million every year. The second most frequent direct cause of death is sepsis, responsible for most late postpartum deaths. During the 19th century puerperal sepsis took on epidemic propor￾tions, particularly in lying-in hospitals. The introduction of aseptic techniques brought a spectacular reduction of its importance in the developed world (13). However, sepsis is still a significant threat in many developing countries. One out of 20 women giving Table 4.1 Incidence of major complications of childbirth, worldwide Complication Incidence Number Case-fatality Maternal Main sequelae DALYs lost (% of of cases rate (%) deaths in for survivors (000) live births) per year 2000 Postpartum 10.5 13 795 000 1 132 000 Severe anaemia 4 418 haemorrhage Sepsis 4.4 5 768 000 1.3 79 000 Infertility 6 901 Pre-eclampsia 3.2 4 152 000 1.7 63 000 Not well evaluated 2 231 and eclampsia Obstructed labour 4.6 6 038 000 0.7 42 000 Fistula, 2 951 incontinence Source: (12)

64 The World Health Report 2005 birth develops an infection, which needs prompt treatment so as not to become fatal or leave sequelae (14 ). Puerperal sepsis leads to tubal occlusion and infertility in 450 000 women per year. Hypertensive disorders of pregnancy(pre-eclampsia and eclampsia)-which are as- sociated with high blood pressure and convulsions- are the cause of 12% of maternal deaths. They usually occur during pregnancy but also during childbirth(15). Mild pre eclampsia can be monitored in pregnancy, but the transition to severe pre-eclampsia or eclampsia requires care in a hospital environment. Obstructed labour -owing to disproportion between the fetal head and the mother's pelvis, or to malposition or malpresentation of the fetus during labour varies in incidence:as low as 1% in some populations but up to 20%in others.It accounts for around 8%of maternal deaths globally, while the baby may be stillborn, suffer asphyxia and brain damage or die soon after birth. Skilled practitioners, such as mid- wives, can deal with many of these problems before labour becomes obstructed, or recognize slow progress and refer for caesarean section or instrumental delivery. Dis abilities associated with obstructed labour that is dealt with late or inadequately can be very significant both for mother and child(12). For the mother the most distressing potential long-term conditions following obstructed labour are obstetric fistulae(see B0x4.1) Of the 136 million women who give birth each year, some 20 million experience preg- nancy-related illness after birth(30 ) The list of morbidities is very diverse, ranging from fever to psychosis, and the range of care responses needed is correspondingly varied. For those women who have almost died in childbirth, recovery from organ failure, uterine rupture, fistulas and other severe complications can be long, painful and leave lasting sequelae. Other, non-life-threatening illnesses are frequent as well in India, for example, 23% of women report health problems in the first months after delivery (31). Some of these problems are temporary but others become chronic. They include urinary incontinence, uterine prolapse, pain following poor repair of episiotomy Box 4.1 Obstetric fistula: surviving with dignity An obstetric fistula is a devastating yet often in silence, rather than seek medical help, even other partners launched a Global Campaign for neglected injury that occurs as a result of if such help were available. the Elimination of Fistula (27) prolonged or obstructed labour (usually This devastating condition affects more Good-quality first-level and back resuiting in a stillbirth as well). Trauma to the than two million women worldwide(21). There at childbirth prevents fistula. Once the con- vaginal wall results in an opening between are an estimated 50 000 to 100 000 additional dition has occurred it is treatable(28). The the vagina and the bladder, the vagina and cases each year (22), a figure some believe to plight of women living with fistula is e rectum, or both; this leaves the woman be an underestimate(23, 24). Most are young reminder that programmatic concerns should eaking urine and/or faeces continuously from women or adolescents. Early marriage, early go beyond simply preventing maternal deaths the vagina(16). Without surgical repair, the or repeated childbearing, along with poverty Decision-makers and professionals should be physical consequences of fistula are severe, and lack of access to quality health care in aware that the problem is not infrequent, that and include vaginal incontinence, a fetid odour, pregnancy and at birth, are the main deter- the girls and women who suffer from it nee inants (25). Fistulae occur in areas where support to get access to treatment, that enough infertility and often early mortality(16-18). access to care at childbirth is limited, or of poor trained doctors and nurses need to be available The social consequences of fistula are quality, mainly in sub-Saharan Africa and parts to provide surgical repair, and that further sup- immense: women with fistula are ostracized of southern Asia (26). In the areas where fis port is necessary for women who retum home and frequently abandoned by their husbands, tula are most often seen, few hospitals offer after treatment. Collective action can eliminate families and communities; they often become the necessary corrective surgery, which is not fistula and ensure that girls and women wh destitute and must struggle to survive (19, 20). profitable and for which surgeons and nurses suffer this devastating condition are treated so To make matters worse, many women are so are often poorly trained. In 2003, the United that they can live in dignity (29) embarrassed by this condition that they suffer Nations Population Fund along with WHO and

64 The World Health Report 2005 birth develops an infection, which needs prompt treatment so as not to become fatal or leave sequelae (14). Puerperal sepsis leads to tubal occlusion and infertility in 450 000 women per year. Hypertensive disorders of pregnancy (pre-eclampsia and eclampsia) – which are as￾sociated with high blood pressure and convulsions – are the cause of 12% of maternal deaths. They usually occur during pregnancy but also during childbirth (15). Mild pre￾eclampsia can be monitored in pregnancy, but the transition to severe pre-eclampsia or eclampsia requires care in a hospital environment. Obstructed labour – owing to disproportion between the fetal head and the mother’s pelvis, or to malposition or malpresentation of the fetus during labour – varies in incidence: as low as 1% in some populations but up to 20% in others. It accounts for around 8% of maternal deaths globally, while the baby may be stillborn, suffer asphyxia and brain damage or die soon after birth. Skilled practitioners, such as mid￾wives, can deal with many of these problems before labour becomes obstructed, or recognize slow progress and refer for caesarean section or instrumental delivery. Dis￾abilities associated with obstructed labour that is dealt with late or inadequately can be very significant both for mother and child (12). For the mother the most distressing potential long-term conditions following obstructed labour are obstetric fistulae (see Box 4.1). Of the 136 million women who give birth each year, some 20 million experience preg￾nancy-related illness after birth (30). The list of morbidities is very diverse, ranging from fever to psychosis, and the range of care responses needed is correspondingly varied. For those women who have almost died in childbirth, recovery from organ failure, uterine rupture, fistulas and other severe complications can be long, painful and leave lasting sequelae. Other, non-life-threatening illnesses are frequent as well: in India, for example, 23% of women report health problems in the first months after delivery (31). Some of these problems are temporary but others become chronic. They include urinary incontinence, uterine prolapse, pain following poor repair of episiotomy in silence, rather than seek medical help, even if such help were available. This devastating condition affects more than two million women worldwide (21). There are an estimated 50 000 to 100 000 additional cases each year (22), a figure some believe to be an underestimate (23, 24). Most are young women or adolescents. Early marriage, early or repeated childbearing, along with poverty and lack of access to quality health care in pregnancy and at birth, are the main deter￾minants (25). Fistulae occur in areas where access to care at childbirth is limited, or of poor quality, mainly in sub-Saharan Africa and parts of southern Asia (26). In the areas where fis￾tulae are most often seen, few hospitals offer the necessary corrective surgery, which is not profitable and for which surgeons and nurses are often poorly trained. In 2003, the United Nations Population Fund along with WHO and An obstetric fistula is a devastating yet often neglected injury that occurs as a result of prolonged or obstructed labour (usually resulting in a stillbirth as well). Trauma to the vaginal wall results in an opening between the vagina and the bladder, the vagina and the rectum, or both; this leaves the woman leaking urine and/or faeces continuously from the vagina (16). Without surgical repair, the physical consequences of fistula are severe, and include vaginal incontinence, a fetid odour, frequent pelvic and/or urinary infections, pain, infertility and often early mortality (16–18). The social consequences of fistula are immense: women with fistula are ostracized and frequently abandoned by their husbands, families and communities; they often become destitute and must struggle to survive (19, 20). To make matters worse, many women are so embarrassed by this condition that they suffer other partners launched a Global Campaign for the Elimination of Fistula (27). Good-quality first-level and back-up care at childbirth prevents fistula. Once the con￾dition has occurred it is treatable (28). The plight of women living with fistula is a powerful reminder that programmatic concerns should go beyond simply preventing maternal deaths. Decision-makers and professionals should be aware that the problem is not infrequent, that the girls and women who suffer from it need support to get access to treatment, that enough trained doctors and nurses need to be available to provide surgical repair, and that further sup￾port is necessary for women who return home after treatment. Collective action can eliminate fistula and ensure that girls and women who suffer this devastating condition are treated so that they can live in dignity (29). Box 4.1 Obstetric fistula: surviving with dignity

attending to 136 million births, every year 65 and perineal tears, nutritional deficiencies, depression and puerperal psychosis, and mastitis (32)(see Box 4.2). Even less is known about these morbidities than about maternal deaths. They are difficult to quantify, owing to problems with definitions and inadequate records (33). More and more reliable information on the whole range of morbidities would be an important step towards better planning of services and improved care around childbirth. SKILLED PROFESSIONAL CARE. AT BIRTH AND AFTERWARDS Immediate and effective professional care during and after labour and delivery can make the difference between life and death for both women and their newborns as complications are largely unpredictable and may rapidly become life-threatening (34, 35). Both maternal and neonatal mortality are lower in countries where mothers giv- ing birth get skilled professional care, with the equipment, drugs and other supplies needed for the effective and timely management of complications (10, 34). The history of successes and failures in reducing maternal mortality(including in industrialized countries)shows that this is not a spurious statistical association(3, 36). Reversals in maternal and neonatal mortality in countries where health systems have broken down provide further confirmation that care matters Successes and reversals: a matter of building health systems Industrialized countries halved their maternal mortality in the early 20th century by providing professional midwifery care at childbirth; they further reduced it to current historical lows by improving access to hospitals after the Second World War (37 ). Quite a number of developing countries have gone the same way over the last few decades 3). One of the earliest and best-documented examples is Sri Lanka, where maternal Box 4.2 Maternal depression affects both mothers and children Women are between two and three times more unwanted pregnancy; ndent of other risk factors. the infants and ikely to experience depression and anxiety than poor relationship with a partner, including children of mothers who are depressed, espe infants and young children are more vulnerable. providing insufficient practical or emotional have significantly lower birth weight, are mor Depression in women during pregnancy and pport, having little involvement in infant than twice as likely to be underweight at age six in the year after birth has been reported in all care, holding traditional rigid sex role months, are three times more likely to be short cultures. Rates vary considerably, but average expectations, or being coercive or violent; age at six months, have significantly poorer about 10-15% in industrialized countries. lack of practical and emotional support, or long-term cognitive development, have higher Contrary to what was previously thought, even criticism from mother or mother-in-law, tes of antisocial behaviour, hyperactivity and higher rates are reported from developing insufficient social support, including absence attention difficulties, and more frequently expe countries. This contributes substantially to of attachment to a peer group, few confiding rience emotional problems. maternal mortality and morbidity Parasuicide relationships and lack of assistance in Effective psychological and pharmacological thoughts of suicide or actual self-harm- crises treatment strategies for depression exist. In occurs in up to 20% of mothers in developing poverty and social adversity, including industrialized countries less than half of the countries. It is associated with entrapment crowded living conditions and lack of mothers who would benefit from such treat- intolerable situations such as unwanted employment ment receive it. The situation is much worse pregnancy(particularly in young single previous personal history of depression or in the developing countries where care may be women), forced displacement as a refugee, or ast psychiatric hospitalization available to only 5% of women. It is important intractable poverty. Suicide is a leading cause persistent poor physical health hat maternal, newborn and child health pi of maternal mortality in countries as diverse as coincidental adverse life events, such as the grammes recognize the importance of these Many factors contribute to maternal depres- Maternal depression has serious physical and health workers for recognizing, assessing and sion during pregnancy and after birth, including: psychological consequences for children. Inde- treating mothers with depression

attending to 136 million births, every year 65 and perineal tears, nutritional deficiencies, depression and puerperal psychosis, and mastitis (32) (see Box 4.2). Even less is known about these morbidities than about maternal deaths. They are difficult to quantify, owing to problems with definitions and inadequate records (33). More and more reliable information on the whole range of morbidities would be an important step towards better planning of services and improved care around childbirth. SKILLED PROFESSIONAL CARE: AT BIRTH AND AFTERWARDS Immediate and effective professional care during and after labour and delivery can make the difference between life and death for both women and their newborns, as complications are largely unpredictable and may rapidly become life-threatening (34, 35). Both maternal and neonatal mortality are lower in countries where mothers giv￾ing birth get skilled professional care, with the equipment, drugs and other supplies needed for the effective and timely management of complications (10, 34). The history of successes and failures in reducing maternal mortality (including in industrialized countries) shows that this is not a spurious statistical association (3, 36). Reversals in maternal and neonatal mortality in countries where health systems have broken down provide further confirmation that care matters. Successes and reversals: a matter of building health systems Industrialized countries halved their maternal mortality in the early 20th century by providing professional midwifery care at childbirth; they further reduced it to current historical lows by improving access to hospitals after the Second World War (37). Quite a number of developing countries have gone the same way over the last few decades (3). One of the earliest and best-documented examples is Sri Lanka, where maternal in silence, rather than seek medical help, even if such help were available. This devastating condition affects more than two million women worldwide (21). There are an estimated 50 000 to 100 000 additional cases each year (22), a figure some believe to be an underestimate (23, 24). Most are young women or adolescents. Early marriage, early or repeated childbearing, along with poverty and lack of access to quality health care in pregnancy and at birth, are the main deter￾minants (25). Fistulae occur in areas where access to care at childbirth is limited, or of poor quality, mainly in sub-Saharan Africa and parts of southern Asia (26). In the areas where fis￾tulae are most often seen, few hospitals offer the necessary corrective surgery, which is not profitable and for which surgeons and nurses are often poorly trained. In 2003, the United Nations Population Fund along with WHO and An obstetric fistula is a devastating yet often neglected injury that occurs as a result of prolonged or obstructed labour (usually resulting in a stillbirth as well). Trauma to the vaginal wall results in an opening between the vagina and the bladder, the vagina and the rectum, or both; this leaves the woman leaking urine and/or faeces continuously from the vagina (16). Without surgical repair, the physical consequences of fistula are severe, and include vaginal incontinence, a fetid odour, frequent pelvic and/or urinary infections, pain, infertility and often early mortality (16–18). The social consequences of fistula are immense: women with fistula are ostracized and frequently abandoned by their husbands, families and communities; they often become destitute and must struggle to survive (19, 20). To make matters worse, many women are so embarrassed by this condition that they suffer other partners launched a Global Campaign for the Elimination of Fistula (27). Good-quality first-level and back-up care at childbirth prevents fistula. Once the con￾dition has occurred it is treatable (28). The plight of women living with fistula is a powerful reminder that programmatic concerns should go beyond simply preventing maternal deaths. Decision-makers and professionals should be aware that the problem is not infrequent, that the girls and women who suffer from it need support to get access to treatment, that enough trained doctors and nurses need to be available to provide surgical repair, and that further sup￾port is necessary for women who return home after treatment. Collective action can eliminate fistula and ensure that girls and women who suffer this devastating condition are treated so that they can live in dignity (29). Box 4.1 Obstetric fistula: surviving with dignity • unwanted pregnancy; • poor relationship with a partner, including his being unavailable during the baby’s birth, providing insufficient practical or emotional support, having little involvement in infant care, holding traditional rigid sex role expectations, or being coercive or violent; • lack of practical and emotional support, or criticism from mother or mother-in-law; • insufficient social support, including absence of attachment to a peer group, few confiding relationships and lack of assistance in crises; • poverty and social adversity, including crowded living conditions and lack of employment; • previous personal history of depression or past psychiatric hospitalization; • persistent poor physical health; • coincidental adverse life events, such as the loss of a partner. Maternal depression has serious physical and psychological consequences for children. Inde￾Women are between two and three times more likely to experience depression and anxiety than men. Mothers who are pregnant or caring for infants and young children are more vulnerable. Depression in women during pregnancy and in the year after birth has been reported in all cultures. Rates vary considerably, but average about 10–15% in industrialized countries. Contrary to what was previously thought, even higher rates are reported from developing countries. This contributes substantially to maternal mortality and morbidity. Parasuicide – thoughts of suicide or actual self-harm – occurs in up to 20% of mothers in developing countries. It is associated with entrapment in intolerable situations such as unwanted pregnancy (particularly in young single women), forced displacement as a refugee, or intractable poverty. Suicide is a leading cause of maternal mortality in countries as diverse as the United Kingdom and Vietnam. Many factors contribute to maternal depres￾sion during pregnancy and after birth, including: pendent of other risk factors, the infants and children of mothers who are depressed, espe￾cially those experiencing social disadvantage, have significantly lower birth weight, are more than twice as likely to be underweight at age six months, are three times more likely to be short for age at six months, have significantly poorer long-term cognitive development, have higher rates of antisocial behaviour, hyperactivity and attention difficulties, and more frequently expe￾rience emotional problems. Effective psychological and pharmacological treatment strategies for depression exist. In industrialized countries less than half of the mothers who would benefit from such treat￾ment receive it. The situation is much worse in the developing countries where care may be available to only 5% of women. It is important that maternal, newborn and child health pro￾grammes recognize the importance of these problems and provide support and training to health workers for recognizing, assessing and treating mothers with depression. Box 4.2 Maternal depression affects both mothers and children

66 The World Health Report 2005 mortality levels, compounded by malaria, had remained well above 1500 per 100 000 births in the first half of the 20th century-despite 20 years of antenatal care. In this period midwifery was professionalized, but access remained limited. From around 1947 mortality ratios started to drop closely following improved access and the de velopment of health care facilities in the country (38) This brought mortality ratios down to between 80 and 100 per 100000 births by 1975. Improved management and quality then further lowered them to below 30 in the 1990s, according to Ministry of Health time series (36). Malaysia also has a long-standing tradition of professional midwifery-since 1923 Maternal mortality was reduced from more than 500 per 100 000 births in the early 1950s to around 250 in 1960. The country then gradually improved survival of mothers and newborns further by introducing a matemal and child health programme. a dis trict health care system was introduced and midwifery care was stepped up through a network of "low-risk delivery centres, backed up by high-quality referral care, all with close and intensive quality assurance and on the initiative of the public sector authorities. This brought maternal mortality to below 100 per 100 000 by around 1975, pe Until the 1960s Thailand had maternal mortality levels well above 400 per 100 births, the equivalent of those in the United Kingdom in 1900 or the USA in During the 1960s traditional birth attendants were gradually substituted by certi fied village midwives, 7191 of whom were newly registered within a 10-year period mortality came down to between 200 and 250 per 100 000 births. During the 1970s Figure 4.2 Maternal mortality since the 1960s in Malaysia, Sri Lanka and Thailand 400 Thailand Sri Lanka Malaysia 64666870 808284868890 7200 new midwife 8 814 new midwife registrations registrations Capacity of communty. Shift to births in hospital in hospital Rural health services Skilled attendance from 70% to 90% TBAS replaced by skilled attendants shift to births in hospital

66 The World Health Report 2005 mortality levels, compounded by malaria, had remained well above 1500 per 100 000 births in the first half of the 20th century – despite 20 years of antenatal care. In this period midwifery was professionalized, but access remained limited. From around 1947 mortality ratios started to drop, closely following improved access and the de￾velopment of health care facilities in the country (38). This brought mortality ratios down to between 80 and 100 per 100 000 births by 1975. Improved management and quality then further lowered them to below 30 in the 1990s, according to Ministry of Health time series (36). Malaysia also has a long-standing tradition of professional midwifery – since 1923. Maternal mortality was reduced from more than 500 per 100 000 births in the early 1950s to around 250 in 1960. The country then gradually improved survival of mothers and newborns further by introducing a maternal and child health programme. A dis￾trict health care system was introduced and midwifery care was stepped up through a network of “low-risk delivery centres”, backed up by high-quality referral care, all with close and intensive quality assurance and on the initiative of the public sector authorities. This brought maternal mortality to below 100 per 100 000 by around 1975, and then to below 50 per 100 000 by the 1980s (36, 39, 40). Until the 1960s Thailand had maternal mortality levels well above 400 per 100 000 births, the equivalent of those in the United Kingdom in 1900 or the USA in 1939. During the 1960s traditional birth attendants were gradually substituted by certi- fied village midwives, 7191 of whom were newly registered within a 10-year period: mortality came down to between 200 and 250 per 100 000 births. During the 1970s Maternal mortality ratio per 100 000 live births 1960 Thailand 450 Figure 4.2 Maternal mortality since the 1960s in Malaysia, Sri Lanka and Thailand Sri Lanka Malaysia 400 350 300 250 200 150 100 50 0 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 7200 new midwife registrations 18 814 new midwife registrations Shift to births Capacity of community in hospital hospitals quadrupled Increased access to public sector midwives Shift to births in hospital Quality improvement Rural health services TBAs replaced by skilled attendants Skilled attendance from 70% to 90% Shift to births in hospitals Source: (3)

attending to 136 million births, every year 67 the registration of midwives was stepped up with 18 314 new registrations. Midwives ecame key figures in many villages, proud of their professional and social status Mortality dropped steadily and caught up with Sri Lanka by 1980. The main effort then went into strengthening and equipping district hospitals. Within 10 years, from 1977 to 1987, the number of beds in small community hospitals quadrupled, from 2540 to 10 800, and the number of doctors in these districts rose from a few hundred to 1339. By 1990 the maternal mortality ratio was below 50 per 100 000 births(see Figure 4.2) More recently, Egypt reduced its maternal mortality by more than 50% in eight years, from 174 in 1993 to 84 per 100 000 live births in 2000: major efforts to promot safer motherhood doubled the proportion of births attended by a doctor or nurse and improved access to emergency obstetric care (41). Honduras brought matemal deaths down from 182 to 108 per 100 000 between 1990 and 1997 by opening and staffing seven referral hospitals and 226 rural health centres and by increasing the number of health personnel and skilled attendants (42) These examples illustrate that long-term initiatives and efforts to provide skilled professional care at birth produce results; unfortunately, the converse is true as well. Breakdowns of access to skilled care may rapidly result in an increase of unfavour ble outcomes, as in Malawi or Mongolia(see Chapter 1). In Tajikistan too, economic upheaval following the break-up of the Soviet Union and newly won independence in 1991, compounded by civil war, led to a startling erosion of the capacity of the health care system to provide accessible care and a dramatic tenfold increase in the proportion of women giving birth at home with no skilled assistance (43 ) Maternal Some countries are trying to make good the shortfall in the number of midwives. This picture of lurse-midwifery graduates was taken on the day of their graduation from the University of Malawi amuzu College of Nursing

attending to 136 million births, every year 67 the registration of midwives was stepped up with 18 314 new registrations. Midwives became key figures in many villages, proud of their professional and social status. Mortality dropped steadily and caught up with Sri Lanka by 1980. The main effort then went into strengthening and equipping district hospitals. Within 10 years, from 1977 to 1987, the number of beds in small community hospitals quadrupled, from 2540 to 10 800, and the number of doctors in these districts rose from a few hundred to 1339. By 1990 the maternal mortality ratio was below 50 per 100 000 births (see Figure 4.2). More recently, Egypt reduced its maternal mortality by more than 50% in eight years, from 174 in 1993 to 84 per 100 000 live births in 2000: major efforts to promote safer motherhood doubled the proportion of births attended by a doctor or nurse and improved access to emergency obstetric care (41). Honduras brought maternal deaths down from 182 to 108 per 100 000 between 1990 and 1997 by opening and staffing seven referral hospitals and 226 rural health centres and by increasing the number of health personnel and skilled attendants (42). These examples illustrate that long-term initiatives and efforts to provide skilled professional care at birth produce results; unfortunately, the converse is true as well. Breakdowns of access to skilled care may rapidly result in an increase of unfavour￾able outcomes, as in Malawi or Mongolia (see Chapter 1). In Tajikistan too, economic upheaval following the break-up of the Soviet Union and newly won independence in 1991, compounded by civil war, led to a startling erosion of the capacity of the health care system to provide accessible care and a dramatic tenfold increase in the proportion of women giving birth at home with no skilled assistance (43). Maternal Some countries are trying to make good the shortfall in the number of midwives. This picture of nurse-midwifery graduates was taken on the day of their graduation from the University of Malawi Kamuzu College of Nursing. R.M. Kershbaumer/University of Pennsylvania School of Nursing

68 The World Health Report 2005 ortality ratios rose as a result. Similarly, in Irag, sanctions during the 1990s severely disrupted previously well-functioning health care services, and maternal mortality ratios increased from 50 per 100 000 in 1989 to 117 per 100 000 in 1997, and were as high as 294 per 100 000 in central and southen parts of the country (44). Iraq also experienced a massive increase in neonatal mortality during this period: from 25 to 59 per 1000 between 1995 and 2000. The good news is that countries that make a deliberate effort to provide professional childbirth care with midwives and other skilled attendants, backed up by hospitals, improve maternal survival dramatically. As Figure 4.3 shows, it does take time particularly at high levels, difficulties in measuring the evolution of maternal ality may make it difficult to sustain the commitment that is needed Skilled care: rethinking the division of labour The countries that have successfully managed to make motherhood safer have three things in common. First, policy-makers and managers were informed: they were aware that they had a problem, knew that it could be tackled, and decided to act upon that information. Second, they chose a common-sense strategy that proved to be the right one: not just antenatal care, but also professional care at and after childbirth for all mothers, by skilled midwives, nurse-midwives or doctors, backed up by hospital care. Third, they made sure that access to these services- financial and geographi cal- would be guaranteed for the entire population (3). Where information is lacking and commitment is hesitant, where strategies other than that of professionalization of delivery care are chosen (see Box 4.4), or where universal access is not achieved, positive results are delayed. This explains why the USA lagged so far behind a number of northern European countries in the 1930s, and why many developing countries today still have appallingly high levels of matemal mortality ( 3) To provide skilled care at and after childbirth and to deal with complications is a matter of common sense- it is also what mothers and their families ask for. Putting it into practice is a challenge that many countries have not yet been able to meet. They have not been helped by the confusing technical terminology used by the in- ternational community: BEOC, CEOC, BEmOC, CEmOC, EOC', etc, to be provided by skilled attendants"(who may be doctors, nurses or midwives), for whom the division Figure 4.3 Number of years to halve maternal mortality, selected countries malaysia1951-1961 Sri Lanka 1956-1965 Bolivia late-1990s 7 vears 20Lank19741981 Thailand 1974-1981 Egypt1993-2000 4-6 years: Chile1971-1977 Honduras 1975-1981 Colombia 1970-1975 man198198550 Nicaragua 1973-1979 L Maternal mortality ratio per 100 000 live births

68 The World Health Report 2005 mortality ratios rose as a result. Similarly, in Iraq, sanctions during the 1990s severely disrupted previously well-functioning health care services, and maternal mortality ratios increased from 50 per 100 000 in 1989 to 117 per 100 000 in 1997, and were as high as 294 per 100 000 in central and southern parts of the country (44). Iraq also experienced a massive increase in neonatal mortality during this period: from 25 to 59 per 1000 between 1995 and 2000. The good news is that countries that make a deliberate effort to provide professional childbirth care with midwives and other skilled attendants, backed up by hospitals, can improve maternal survival dramatically. As Figure 4.3 shows, it does take time, and, particularly at high levels, difficulties in measuring the evolution of maternal mortality may make it difficult to sustain the commitment that is needed. Skilled care: rethinking the division of labour The countries that have successfully managed to make motherhood safer have three things in common. First, policy-makers and managers were informed: they were aware that they had a problem, knew that it could be tackled, and decided to act upon that information. Second, they chose a common-sense strategy that proved to be the right one: not just antenatal care, but also professional care at and after childbirth for all mothers, by skilled midwives, nurse-midwives or doctors, backed up by hospital care. Third, they made sure that access to these services – financial and geographi￾cal – would be guaranteed for the entire population (3). Where information is lacking and commitment is hesitant, where strategies other than that of professionalization of delivery care are chosen (see Box 4.4), or where universal access is not achieved, positive results are delayed. This explains why the USA lagged so far behind a number of northern European countries in the 1930s, and why many developing countries today still have appallingly high levels of maternal mortality (3). To provide skilled care at and after childbirth and to deal with complications is a matter of common sense – it is also what mothers and their families ask for. Putting it into practice is a challenge that many countries have not yet been able to meet. They have not been helped by the confusing technical terminology used by the in￾ternational community: BEOC, CEOC, BEmOC, CEmOC, EOC1 , etc., to be provided by “skilled attendants” (who may be doctors, nurses or midwives), for whom the division Figure 4.3 Number of years to halve maternal mortality, selected countries 8–9 years: Malaysia 1951–1961 Sri Lanka 1956–1965 Bolivia late-1990s Maternal mortality ratio per 100 000 live births. 6–7 years: Sri Lanka 1974–1981 Thailand 1974–1981 Egypt 1993–2000 Chile 1971–1977 Colombia 1970–1975 4–6 years: Honduras 1975–1981 Thailand 1981–1985 Nicaragua 1973–1979 400 200 100 50

attending to 136 million births, every year 69 of tasks across these various acronyms is often unclear. Part of the confusion lies in the distinction between"basic" and"comprehensive"care, which was originally conceived as a device to monitor facilities, and not as a description of who can give care to whom in any given situation. The acronyms are even more bewildering because of the difference, still disputed, between"essential"and"emergency"care. It is time to clarify the issues Care that is close to women -and safe All mothers and newborns, not just those considered to be at particular risk of devel- oping complications, need skilled maternal and neonatal care provided by profession als at and after birth. there is a value in the rituals surrounding birth, and in keeping these as a central feature of family life. there is a consequent need and demand for care that is close to where and how people live, close to their birthing culture, but at the same time safe, with a skilled professional able to act immediately when largely unpredictable complications occur. The defining features of the type of care that is required is that it should be responsive, accessible in all ways, and that a midwife, a person with equivalent skills, is there to provide it competently to all mothers, with the necessary means and in the right environment. This level of care is appropriately referred to as"first-level"care Labelling it as"basic","primary"or"routine"under- values the complexity and skill-base required to attend to situations that can suddenly and unexpectedly become life-threatening. Table 4.2 summarizes the key features of first-level and back-up matemal and newborn care Recommended packages, the result of an international consensus, are extensively described in published guidelines(see Table 4.2). Most interventions, such as surveil- lance of the progress of labour, psycho-logical support, initiation of breastfeeding and others, have to be implemented for all mothers and newborns in all circumstances other elements in the package-such as manual removal of the placenta or resuscita- TBasic Essential Obstetric Care, Comprehensive Essential Obstetric Care, Basic Emergency Obstetric Care, Comprehensive Emergency Obstetric Care, Emergency Obstetric Care Box 4.3 Screening for high-risk childbirth: a disappointment Antenatal screening has a long history, dating for many years. International development even then say what it is"(55). Six years later, back to the first WHO expert committee on agencies poured resources and efforts into it could be clearly stated that"no amount of motherhood in the early 1950s(45 The idea information, education and communication te those women who will was beguiling in its simplicity. If all women campaigns to mobilize communities around a from those who will not need emergency medi- could be persuaded to attend antenatal minimum of one antenatal visit for all pregnant cal care"(56 ) Indeed, most women who even- care, screening tests could be carried out to women to identify those at risk, and those not tually experience complications have few or no determine which women were at high risk of at risk. The first group was told they should give risk factors, and most of the women with risk developing complications; they could then be birth in a health facility; for the others nothing factors go on to have uneventful pregnancies offered additional care. Although there had further needed to be done. and deliveries. The Rooney report of 1992 for- been evidence, from as early as 1932, that In the early 1980s, the first evidence sur- mally changed the balance to scepticism (57) screening was not very effective (46, 47), risk faced that questioned the cost-effectiveness of Antenatal care is important to further maternal coring systems were exported to developing antenatal screening as a way to reduce mater- and newborn health-but not as a stand-alone untries. They soon became common wisdom nal mortality (52). The accepted wisdom be tegy and not as a screening instrumen 148-51)and, during the 1970s and 1980s, a to be challenged (54), with a growing view that To ensure safe childbirth, on the other hand mainstream doctrine under the label "risk the inety.&o progamme not only renders for all births, even the ones not at risk, accord. ess of antenatal care " as an skilled professional care needs to be available proach"(52, 53). This approach was a core overall screenin component of safe motherhood strategies it less than what it claimed to be; it does not ing to the criteria of the 1980s

attending to 136 million births, every year 69 of tasks across these various acronyms is often unclear. Part of the confusion lies in the distinction between “basic” and “comprehensive” care, which was originally conceived as a device to monitor facilities, and not as a description of who can give care to whom in any given situation. The acronyms are even more bewildering because of the difference, still disputed, between “essential” and “emergency” care. It is time to clarify the issues. Care that is close to women – and safe All mothers and newborns, not just those considered to be at particular risk of devel￾oping complications, need skilled maternal and neonatal care provided by profession￾als at and after birth. There is a value in the rituals surrounding birth, and in keeping these as a central feature of family life. There is a consequent need and demand for care that is close to where and how people live, close to their birthing culture, but at the same time safe, with a skilled professional able to act immediately when largely unpredictable complications occur. The defining features of the type of care that is required is that it should be responsive, accessible in all ways, and that a midwife, or a person with equivalent skills, is there to provide it competently to all mothers, with the necessary means and in the right environment. This level of care is appropriately referred to as “first-level” care. Labelling it as “basic”, “primary” or “routine” under￾values the complexity and skill-base required to attend to situations that can suddenly and unexpectedly become life-threatening. Table 4.2 summarizes the key features of first-level and back-up maternal and newborn care. Recommended packages, the result of an international consensus, are extensively described in published guidelines (see Table 4.2). Most interventions, such as surveil￾lance of the progress of labour, psycho-logical support, initiation of breastfeeding and others, have to be implemented for all mothers and newborns in all circumstances. Other elements in the package – such as manual removal of the placenta or resuscita￾for many years. International development agencies poured resources and efforts into information, education and communication campaigns to mobilize communities around a minimum of one antenatal visit for all pregnant women to identify those at risk, and those not at risk. The first group was told they should give birth in a health facility; for the others nothing further needed to be done. In the early 1980s, the first evidence sur￾faced that questioned the cost-effectiveness of antenatal screening as a way to reduce mater￾nal mortality (52). The accepted wisdom began to be challenged (54), with a growing view that the ineffectiveness of antenatal care “as an overall screening programme not only renders it less than what it claimed to be; it does not Antenatal screening has a long history, dating back to the first WHO expert committee on motherhood in the early 1950s (45). The idea was beguiling in its simplicity. If all women could be persuaded to attend antenatal care, screening tests could be carried out to determine which women were at high risk of developing complications; they could then be offered additional care. Although there had been evidence, from as early as 1932, that screening was not very effective (46, 47), risk scoring systems were exported to developing countries. They soon became common wisdom (48–51) and, during the 1970s and 1980s, a mainstream doctrine under the label “risk approach” (52, 53). This approach was a core component of safe motherhood strategies even then say what it is” (55). Six years later, it could be clearly stated that “no amount of screening will separate those women who will from those who will not need emergency medi￾cal care” (56). Indeed, most women who even￾tually experience complications have few or no risk factors, and most of the women with risk factors go on to have uneventful pregnancies and deliveries. The Rooney report of 1992 for￾mally changed the balance to scepticism (57). Antenatal care is important to further maternal and newborn health – but not as a stand-alone strategy and not as a screening instrument. To ensure safe childbirth, on the other hand, skilled professional care needs to be available for all births, even the ones not at risk, accord￾ing to the criteria of the 1980s. Box 4.3 Screening for high-risk childbirth: a disappointment 1 Basic Essential Obstetric Care, Comprehensive Essential Obstetric Care, Basic Emergency Obstetric Care, Comprehensive Emergency Obstetric Care, Emergency Obstetric Care