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 incontinenceattending 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)