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 and64 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