Tag Archives: World Health Organization

Making a difference in maternal mortality

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It isn't that childbirth is more inherently dangerous in countries where many women die in childbirth than in those where relatively few die. The women who survive, statistically speaking, are getting appropriate help from trained attendants.

"...The main complications that lead to death during pregnancy or childbirth are fairly common among all women, regardless of where they live," write the authors of an article titled "Are We Making Progress in Maternal Mortality?" in the May 26 issue of the New England Journal of Medicine.Pregnant Graffiti

Hemorrhage, which most often occurs right after birth, is the leading cause of pregnancy-related deaths globally, accounting for 35 percent of all deaths in childbirth, according to the World Health Organization. And in fact, hemorrhage was the second most common complication seen in pregnancies in the United States in 2000.

However, most U.S. women who suffered hemorrhage were treated quickly, and survived, say the article's authors, Anne Paxton and Tessa Wardlaw.

WHO identified the second most common cause of maternal death as hypertensive disorders — pre-eclampsia/eclampsia, for example. Again, these disorders are a common problem all over the world, but women with access to good medical care have a good chance of surviving them.

The countries that are most dangerous for pregnant women are those suffering through wars, or burdened with a large population with HIV/AIDS, the authors write.

In general, poor women die in childbirth more often than affluent ones, rural women more often than urban ones. These populations are more vulnerable because they often deliver their babies without the benefit of skilled birth attendants, and lack access to obstetrical services like surgery by Cesarean section.

Sub-Saharan Africa, with widespread political unrest and HIV/AIDS infection, "has the greatest burden of maternal mortality," even though most countries there are seeing "small but promising" decreases in pregnancy-related deaths.

Worldwide, there is considerable cause for hope, Paxton and Wardlaw write. Maternal mortality has decreased globally by more than one-third since 1990, according to United Nations estimates.

"Dramatic improvements in China and other Asian countries...are associated with economic improvement, decreasing fertility rates and strengthening of health systems...," the authors write.

"The overall rate of decline in global maternal mortality, 2.3 percent, is lower than the 5.5 percent MDG target but is heartening nonetheless," they write.

Image: "Pregnant Graffiti" by Petteri Sulonen

Priority medicines for mothers and children

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The World Health Organization has published a list of 30 medicines that can make the difference between life and death for mothers and children younger than 5 years of age.

This list of "priority medicines" was developed by the WHO, the United Nations Population Fund and UNICEF. It is the first such list, the sine qua non for mothers and children regardless of where they are , according to an editorial in the Lancet. (This list should not be confused with WHO's Model List of Essential Medicines.)

"An estimated 8.1 million children under the age of five die every year and an estimated 1,000 women — most of them in developing countries — die every day due to complications during pregnancy or childbirth," states the introduction to the list.

The new publication is something of a "wish list," the Lancet notes, in that five of the medicines to protect young children have not yet been developed.

These are the generic treatments on the list that address conditions that threaten the lives of mothers:

* For post-partum hemorrhage — oxytocin and sodium chloride

* For pre-eclampsia and eclampsia — calcium gluconate injection (for treatment of magnesium toxicity), magnesium sulfate

* For puerperal infection —  ampicillin, metronidasole, gentamicin, misoprostol

* For sexually transmitted diseases — azithromycin for chlamydia, cefixime and, for syphillis, benzathine benzylpenicillin

Malawi eases rule on birth attendants

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The African nation of Malawi will take a new tack in its campaign to improve its maternal-mortality statistics.

Almost immediately after his return from the United Nations meeting in New York on the Millennium Development Goals, President Bingu wa Mutharika lifted a ban on traditional birth attendants.

The fifth MDG is to cut the number of women who die in childbirth worldwide by 75 percent by the year 2015. Malawi, along with a number of other countries, has experienced disappointing progress on Goal 5.

Malawi shares Africa's dismal statistics on maternal mortality; a mother's lifetime chance of dying in childbirth there is 1 in 36, according to the latest figures from the World Health Organization. (HIV/AIDS is a major factor in Malawi.) Not only that, but decreases in the rate of deaths, presently 510 per 100,000 births, have only been running about 3 percent per year since 1990.

Banning TBAs was part of an earlier effort to get more women to deliver their babies with assistants trained in modern medical techniques, who would be able to recognize and respond to emergencies. Only 54 percent of Malawi women delivered their babies in a health-care facility in 2005.

However, one result of the ban has been that more women have delivered their babies without any kind of real birth attendant, traditional or modern, or with TBAs working under the threat of fines.

Dorothy Ngoma, executive director of the National Organization of Nurses and Midwives in Malawi, told The Nation, a daily newspaper in Malawi, "They [TBAs] never really stopped.... What happened is that they went underground."

It appears that President Mutharika decided after the UN summit that training TBAs to be part of the solution made more sense. The president married Callista Chimombo last spring, and the new first lady appears to be taking an active role in addressing the country's poverty.

The Nation reported that her Safe Motherhood Foundation will train 20 TBAs from the countryside next year in modern birth methods. They will then return to serve their communities as midwives.

Healthcare facilities tend to be concentrated in Malawi's cities, while 70 percent of the nation's 15 million people live in rural areas. There are reportedly two doctors for every 100,000 Malawians.

"We should not abandon TBAs, as they are very important to our program of safe motherhood," President Mutharika was quoted as saying in The Nation.

How hospitals can promote breast-feeding

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The Baby Friendly Hospital Initiative, an international program, has created a list of things birth facilities in the United States can do to optimize the chances that mothers will choose to breast-feed their babies.

Here are "The Ten Steps To Successful Breast-feeding," from BFHI USA:

    1. Have a written breast-feeding policy that is routinely communicated to all health-care staff.
    2. Train all health-care staff in skills necessary to implement this policy.
    3. Inform all pregnant women about the benefits and management of breast-feeding.
    4. Help mothers initiate breast-feeding within one hour of birth.
    5. Show mothers how to breast-feed and how to maintain lactation, even if they are separated from their infants.
    6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
    7. Practice “rooming in” — allow mothers and infants to remain together 24 hours a day.
    8. Encourage breast-feeding on demand.
    9. Give no pacifiers or artificial nipples to breast-feeding infants.
    10. Foster the establishment of breast-feeding support groups and refer mothers to them on discharge from the hospital or clinic.

The BFHI is underwritten by the World Health Organization and the United Nations Children's Fund (UNICEF).

Clearing the first hurdle in breast-feeding

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Fewer than 4 percent of births in the United States occur at facilities that are considered "baby friendly," according to the latest Breast-feeding Report Card, issued this week by the Centers for Disease Control and Prevention.Happy baby

That's interesting, in light of the fact that birth is the one point at which the nation's breast-feeding practices actually meet the goals set by Healthy People 2010.

And, it raises some questions: Are American women determined to breast-feed even in the teeth of an unsupportive environment? Or does strong support from the hospital not matter much in their decision? Do problems caused by settings where breast-feeding is not actively promoted only show up later?

Or are environments that come after the birth facility, including families, other medical advisers, child-care centers and workplaces, even less sympathetic to breast-feeding?

Only two hospitals in Illinois, my home state, are among the 99 "baby friendly" facilities recognized by the Baby-Friendly Hospital Initiative as providing "an optimal level of care for infant feeding." These are Pekin Hospital in Pekin and St. John's Hospital in Springfield.

Thirty of the hospitals on the list are in California.

"Although the hospital is not and should not be the only place a mother receives support for breastfeeding, hospitals provide a unique and critical link between the breastfeeding support provided prior to and after delivery," the BFHI's website states.

The BFHI is a joint global effort of the World Health Organization and the United Nations Children's Fund (UNICEF).

A “boob” on the right side of breast-feeding

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New mom Gisele Bundchen touched off a firestorm of criticism when she told the British edition of Harper's Bazaar that mothers around the world should be required by law to breast-feed for six months.

Gisele Bundchen/Wikimedia Commons

Gisele Bundchen

Boston Herald columnist Margery Eagan called Bundchen "a silly twit." Mark Marino, writing on CNN Entertainment's Marquee Blog, ventured that the 30-year-old Brazilian-born supermodel "might have made a boob of herself," based on responses from indignant readers of the blog.

Those included one woman identified as "Angela," who said that having "just popped out a kid" seemed to have given Bundchen the idea she "knows what's best for children and mothers."

Eagan admitted that her "catty little heart leaps with joy" to see a woman so "lucky in looks, in love, in life" whose "perfect foot" keeps finding its way into her "perfect pouty mouth," first touting her painless home birth eight months ago, now with her pronouncement that everyone should be legally required to breast-feed. And in that, Eagan probably stands in for a great many of us who can't help but notice that Bundchen's life is not exactly lived in the trenches.

Bundchen did back down from her provocative statement, writing in her blog, "I am not here to judge.... I think as mothers we are all just trying our best."

Of her backtracking, Eagan wrote, "Too late! Too late!"

But here's the thing. Bundchen has a right to her opinion (she did say it was her opinion), and she is in a position where people ask her her opinion and then print it up in glossy magazines.

Here's another thing: She's not wrong. She's not saying parents should hang their kids out the window by their heels; she's saying every mother should breast-feed for six months.

Sure, plenty of women can't breast-feed, others simply don't want to, and working mothers in this country, at least, have to be highly motivated to keep it up for any length of time. And the logistics — and the politics — of enacting a "worldwide law" mandating six months of breast-feeding for every baby make it, let's say, unlikely.

However, the health benefits of breast-feeding are well documented. The World Health Organization and the American Academy of Pediatrics join Bundchen in recommending that infants be breast-fed exclusively for at least six months. The AAP suggests mothers continue to breast-feed, even as a baby begins to eat other foods, for at least a year in all; the WHO recommends two years or more.

"Breast-feeding can decrease the incidence or severity of conditions such as diarrhea, ear infections and bacterial meningitis. Some studies also suggest that breast-feeding may offer protection against sudden infant death syndrome (SIDS), diabetes, obesity and asthma among others (conditions)," the AAP stated in its 2005 position on breast-feeding.

Researchers recently teased out some of the specifics of the good things breast-feeding does for babies, concluding that breast-feeding represents "an intriguing strategy" to maximize an infant's chances for survival.

But breast-feeding still gets a bad rap from a squeamish public, and even, down in those trenches, from doctors.

"It is tragic that a supermodel-mom dispenses better advice than many doctors and most governmental agencies," wrote pediatrician/author Jay Gordon MD on the Huffington Post. "We must listen if her advice and high profile can save babies' lives."

Lastly, I must say that the world is full of women who think that the fact that they popped out a kid or two makes them experts on parenting. Just usually not as big an expert as people who have never popped out a kid.

Image from Wikimedia Commons

The things they carry

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The latest figures on global maternal mortality, which I've written about in the last two posts here on Birth Story, are encouraging. But are they correct?

The new figures, in a study funded by the Bill and Melinda Gates Foundation, are much more positive than the ones the World Health Organization came up with in 2006. Advocate groups fear that the brighter statistics will slow down progress on making birth safe for women in developing countries.

The New York Times columnist Nicholas Kristof, who has made a specialty of chronicling the dire state of women in the world's least prosperous areas, wrote in his blog "On the Ground" on April 16 that "when women die in childbirth in poor countries, nobody keeps track, and so all these figures are very rough estimates."

Imagine that. A mother dies, and nobody even writes it down.

I am a regular reader of Kristof's column, as he consistently mines the rich vein of human interest stories about indigent women.

Kristof has done some great video work on "On the Ground."  Video gives a face -- and a voice -- to the actual women who are living the difficult lives he writes about.

I would recommend taking a look at Kristof's videos from eastern Congo, although some of them are terribly upsetting, as many of these women have been brutalized in the political unrest there.

Here is one video that is simply illuminating, "What Are You Carrying?"


Nature is not always our friend

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The World Health Organization estimates that the "natural" maternal mortality rate, which women with no access to health care could be expected to suffer, is between 1,000 and 1,500 per 100,000 births.

In Ireland, which has the world's lowest rate of maternal mortality, one woman dies per 100,000 births, so attention to laboring mothers makes a difference. In 2005, the worldwide maternal mortality rate was 402 deaths per 100,000 births.

The highest rates occur in politically unstable parts of Africa and Asia, notably Sierra Leone (2,000 deaths) and Afghanistan (1,900). The rate in the United States is 13, up from 12 the previous year. (All figures are from 2005.)

WHO defines maternal mortality as the death of a woman while pregnant or within 42 days of termination of pregnancy, regardless of the duration or site of the pregnancy, as long as the cause of death is related to or aggravated by the pregnancy or its management, and not from accidental or incidental causes.

Forceps/vacuum birth hazard: Asia survey

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One big surprise of the WHO survey of Asian births was that "operative vaginal delivery" -- the use of forceps or vacuum -- had the highest death rate for mothers of any method.

Ninety-seven women died during the 108,000 surveyed births. Of those, 53 died during spontaneous vaginal births, as would be expected, given that those were the majority of births (75,000 deliveries), for a rate of less than .1 percent.

However, of 3,465 OVD births, nine mothers died, a rate of nearly .3 percent. In a commentary that accompanied the WHO report in the medical journal The Lancet, the editors called the figures "a sobering reminder of the dangers of operative deliveries," although they noted that most OVDs are "high-risk situations that cannot be easily avoided."

Twenty-three of the 16,500 mothers having Caesaean sections "with indications" during labor died (more than .1 percent), and one woman died of the 554 having elective C-sections during labor (a rate of nearly .2 percent).

The report also found that women undergoing elective Caesarean section were  far more likely to spend time after the birth in intensive care than women whose births were spontaneous.

The irony is that while many unnecessary C-sections are being performed in some areas, women in other areas who desperately need them are not able to get them, the WHO report notes.

Birth in Asia — The WHO survey

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The rising rate of birth by Caesarean sections has hit Asia, with China reporting that 46 percent of its births now end in surgery, according to a global survey by the World Health Organization reported in the medical journal The Lancet.

Nine countries were targeted in the WHO study -- Cambodia, China, India, Japan, Nepal, Philippines, Sri Lanka, Thailand, and Vietnam -- with births in both small and large institutions examined for two or three months in the capital city and two other regions in each country. In all, about 108,000 births were scrutinized at 122 institutions.

China had the highest rate of Caesarean births in the survey. The country with the next-highest rate was Vietnam, with 36 percent, followed by Thailand, with 34 percent, and Sri Lanka, with 31 percent.

Cambodia had the lowest rate of Caesarean births, 15 percent, which is the rate the WHO and other health groups recommend. The C-section rate over all for the Asian countries surveyed was 27 percent.