ADDRESSING MATERNAL DEATHS IN RURAL CAMEROON

1.     What is a Maternal Death?

Maternal death, or maternal mortality, also obstetrical death is “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes” (WHO)

A maternal death is one for which the certifying physician has designated a maternal condition as the underlying cause of death.

2.     Where do maternal deaths take place today?

Every day, approximately 800 women die from preventable causes related to pregnancy and childbirth. In 2010, 287 000 women died during and following pregnancy and childbirth. 99 per cent of maternal deaths occur in the developing countries (Maternal mortality Fact sheet N°348 May 2012  .Only 1 per cent occurs in developed countries¹. In Cameroon 56% person of births occur in rural settings. Maternal Mortality Ratio stands at 690 per 100 000 births².Tunisia has one of the lowest maternal mortality ratios in Africa (70 per 100 000) while Mozambique, Malawi and Central African Republic blaze the trail with 1 100 per 100 000 births³   

3.     What are the causes of maternal deaths?

Improving maternal health is one of the eight Millennium Development Goals (MDGs) adopted at the 2000 Millennium Summit. A key target is to reduce the maternal mortality ratio (MMR) by three-quarters between 1990 and 2015.

Maternal deaths happen for two reasons: a direct obstetric death which is caused by complication that develops directly as a result of pregnancy, delivery or the postpartum period; an indirect obstetric death which is due to existing medical conditions that are made worse by delivery or pregnancy. 

 

Global estimates of the causes of maternal deaths, 1997-2007

Source: WHO 2010. *Nearly all (99%) abortion deaths are due to unsafe abortion. **This category includes deaths due to obstructed labor or anaemia.

There are five major medical causes of direct obstetric death: haemorrhage (35 %); complications of unsafe abortion (9%); pregnancy-induced hypertension especially eclampsia (18%); infection (8 %); obstructed labor (11 %) and embolism (1%) ⁴

Direct obstetric deaths account for about 75 per cent of all maternal deaths in developing countries with haemorrhage remaining the leading cause of maternal mortality. Indirect obstetric deaths account for about 25 percent of all maternal deaths in developing countries ⁵

In Cameroon the situation is compounded by an incongruent health personnel number to the ever growing population. One doctor is to 10,083 people while one pharmacist is to 250,000 people. One midwife is to 200,000 inhabitants while one assistant midwife is to 200,000 inhabitants. One nurse is to 2,242 people while one nursing aid is to 3,100 inhabitants ⁶

1.     What has been done to prevent maternal deaths?

In Cameroon most efforts have been concentrated on delivery of maternal services especially antenatal care other than emergency obstetric care, training traditional birth attendants and community mobilizations.

2.     Have these efforts been effective?

No. Although there has been significant progress maternal mortality rates in Cameroon oscillate at 560 – 600 deaths per 100 000 live births.

3.     Why have they not worked?

Before answering this question, one must take note of the most important fact about maternal deaths from complications: most complications cannot be predicted and prevented All pregnant women are at risk of obstetric complications. Most life-threatening complications occur during labor and delivery, and these cannot all be predicted. Prenatal screening does not identify all of the women who will develop complications ⁷. Women not identified as "high-risk" can and do develop obstetric complications. Most obstetric complications occur among women with no risk factors.

The goal now should be to shift focus and concentrate on improving efficient delivery of care for emergency obstetric complications in addition to ongoing maternal health care services ⁸

4.     What is the role of traditional birth attendants or TBAs on reduction of maternal deaths?

Mothers in rural communities prefer to give birth at home because most TBAs do not charge anything for deliveries and are willing to make house visits, which allow the mother the privacy that many prefer.

TBAs cannot be effective in preventing maternal deaths if they are not recognized in the health care system, nor motivated or supplied with delivery kits to assist them. They are not midwives or medical professionals and do not have the lifesaving skills necessary to deal with life-threatening problems.

With availability of requisite tools and equipment, close supportive supervision, access to continuing education and recognition by the formal health system, trained traditional birth attendants can effectively contribute towards efforts to decrease maternal and newborn mortality rates in Cameroon

Health care systems should draft policies that enhance the activities and integration of traditional birth attendants into modern health care systems. Considering traditional birth attendants as link care providers who identify complications and refer to health facilities is an option not without challenges on the social and psychological status of TBAs. Thus it is expedient to explore the concept of TBAs as link care providers vis-a-vis motivations, constraints, consequences and whether TBAs believe repositioning them as “links to skilled care” and support providers is acceptable/feasible to them and women and families. Much more is to explore in-depth perceived barriers, motivators, enabling factors.

We believe TBAs have a better understanding of who comprises their own social networks; the social networks of locality; social networks of elder female family influentials: social networks of husbands/community leaders and influentials. To achieve these their social status must be respected and implore them on exploring how these social networks might be best used to rapidly spread information about improved obstetric care practices.

5.     And what about community mobilization/involvement?    

Community education and mobilization to make early decision to seek care is crucial to overcoming the maternal mortality cliff. Community-level activities, such as forming and enhancing community women's groups and strengthening community education in order to foster greater responsibility for self care and early decision to seek care ⁹. This approach relies on community women to identify and prioritize maternal and neonatal health problems prevalent in the community (auto-diagnosis).

Training Community Motivators to improve community awareness of obstetric complications, to establish village action groups for community loan funds, blood donation and emergency transport, to establish links with pregnant women in the community, and to facilitate referral for women with complications. (Midwife Training in Cameroon)

Formation of Community Blood Donor Associations through community mobilization sessions and non-cash incentives, such as certificates of honor, free blood screening and priority assurance if a family member needed blood

Without health facilities to provide life-saving services, women with complications will die. That’s a fact. Thus, the simple truth is community mobilization efforts will not amount to anything if there are no midwives and doctors in health facilities; if there is no blood, antibiotics, and other drugs; if there is no functioning operating theatre; and in short, if there is no functioning health facility.

6.     Given all these, what can then be done to prevent maternal deaths and disabilities?

Agencies and governments have to ensure that health facilities are able to provide emergency obstetric care (EmOC) services. And that these health facilities are supported by a functioning referral system.

7.     What is EmOC?

EmOC or emergency obstetric care refers to the functions necessary to save lives. They are called Signal Functions and are grouped as basic and comprehensive EmOC: Basic EmOC include:

·         Administer parenteral antibiotics

·         Administer parenteral oxytocic drugs

·         Administer parenteral anticonvulsants for pre-eclampsia and eclampsia

·         Perform manual removal of placenta

·         Perform removal of retained products

·         Perform assisted vaginal delivery

Comprehensive Obstetric Care includes all basic functions above, plus

·         Caesarean section

·         Safe blood transfusions

·         Care to sick and low birth-weight newborns including resuscitation

8.     How does EmOC differ from Essential Obstetric Care or EOC?

WHO issued several publications presenting the full list of services that should be provided during pregnancy and child birth. This package of services is often referred to as essential obstetric care or EOC. Often, EOC is used interchangeably with EmOC. This does not matter as long as the terms are clearly defined and the signal functions are clearly established.

9.     How can Emergency Obstetric Care (EmOC) avert maternal deaths and disabilities?

If deaths due to pregnancy and delivery are to be substantially reduced, women with complications must have prompt access to adequate emergency obstetric care. In order to avert maternal deaths and disabilities, the focus must be placed on ensuring that women have access to quality EmOC. This entails upgrading peripheral facilities to provide basic and comprehensive obstetric care, i.e., renovating and maintaining health facilities as well as supplying and equipping these appropriately; training health staff to manage obstetric complications as well as the complications of the newborn; training staff to efficiently manage the health facilities; ensuring that a functioning referral system is in place which links peripheral facilities to district health facilities or referral centers that can provide EmOC ¹⁰.

Every pregnant woman needs access to facilities with capabilities to provide emergency obstetric care (EOC). Neither effective prenatal care nor identifying risk will help women if EOC is not available, not accessible, or not utilized.

Access to emergency obstetric care (EmOC) for all pregnant women with complications is one of the 3 pillars of the reduction of maternal mortality, the fifth MDG

10.  Barriers to appropriate EOC?

The "3 Delays Model" developed by the Prevention of Maternal Mortality (PMM) Network identifies the points at which delay to EOC can occur ⁹

1. Delay in deciding to seek care;
2. Delay in reaching a first referral level facility and 
3. Delay in actually receiving care after arriving at the facility. The PMM Network believes the delay in actually receiving care after arriving at the facility the most critical

Source: UNFPA http://www.unfpa.org/public/home/mothers  

11.     What influences decisions to seek care under emergency conditions?

Even where facilities with capabilities for EOC are easily accessible, women may not use them ¹¹.

Women's status in the immediate and extended family generally underlies and shapes the decision to seek care¹². Some women cannot and do not decide on their own to seek care; the decision belongs to a spouse or senior members of the family ¹³.

Other factors include:

Perceived severity of the complication: Pregnancy and delivery are regarded as natural processes and signs and symptoms of complications are not always recognized as reasons for concern. In some areas prolonged labor is not considered a complication and reason to seek care until a couple of days have elapsed¹². Failure to recognize the severity of symptoms is also a major reason for delay in seeking care¹³.

Societal expectations interfere with the use of health services in emergency conditions. Delivery at home remains one way for women to achieve status. For example, a woman who has to go to a hospital for delivery is thought to have failed in her essential role as a woman and is stigmatized¹². In Benin, women of the Bariba tribe are expected to be stoic during labor and delivery, and the woman who manages to deliver without calling for assistance is especially esteemed¹⁴

Culture and tradition have great influence on the decision to seek care and, therefore, on maternal morbidity and mortality. The requirement that care must be given by a woman has hindered the use of health care services.

The necessity of traveling long distances (often due to the inequitable distribution of facilities) and the lack of transport are deterrents in deciding to seek care, as is dissatisfaction with staff attitudes and performance.

12.     Are there barriers to reaching a facility with EOC capabilities?

Once a decision has been made that a complication needs medical intervention, availability of transportation and easy accessibility to a facility with EOC capabilities become factors of paramount importance¹³.

Reasons forwarded are:

• No ambulances are available and
• In remote villages, no car passes for days.
• Condition of the roads. Travelling on bad roads itself was considered a cause of hemorrhage),
• Travel costs have been identified as barriers to reaching a facility.

Some pregnant women would go to a traditional practitioner closer by rather than risk the frustration and expense of going to a distant facility ¹².

13.      What are the hindrances to adequate and appropriate treatment at EOC facilities?

Long admission-to-treatment intervals at EOC facilities: This is most often caused by shortage or lack of essential supplies and equipment, including drugs, gloves, sutures, and anesthetic agents at the facilities, forcing the patient to wait while relatives try to acquire required drugs and supplies in private pharmacies ¹⁵.

Difficulty obtaining blood for transfusion is a major obstacle in the management of obstetric emergencies¹⁶. Thus patients with ruptured uterus who are unable to have a blood transfusion have lower survival rates. Most of the health care facilities offering EOC do not have blood banks or have blood banks that are inadequately stocked¹².

Lack of adequate operating theater space at the facility also contributed to treatment delays, since obstetric emergency cases had to compete with other surgical cases for the single general operating theatre¹⁵.

Lack of appropriately trained staff: Avoidable factors for maternal mortality such as: inadequate resuscitation of women suffering from hemorrhage and septic shock, insufficient antibiotic therapy and inadequate skills in surgery and anesthesia are often due to inadequate treatment by incompetent staff ¹³

Lack of supervision of staff is another avoidable factor for maternal mortality. The responsibility for managing emergency complications is often shouldered by relatively junior staff who fail to diagnose/recognize the severity of the complications ¹³.

Complacency attitudes among staff are among the major barriers¹⁷. Most of the staff (incompetent) are convinced that maternal deaths are due to circumstances beyond their control such as delayed arrivals, cultural factors, and lack of drugs and equipment. All these reasons justify passivity especially when coupled with low staff morale due to low pay. Staff tend to forget their potential capacity to solve problems and few or no attempts are made to look for appropriate solutions to obvious problems

14.     How can we improve quality of EOC?

Poor services at EOC facilities are a major reason for pregnant women not seeking care. Midwives should be trained to identify and manage obstetric complications. An obstetric first aid box with essential drugs and supplies should be introduced ¹⁸.

The following approaches have been taken to improve quality of EOC.

a. Training in Life Saving Skills:

The MotherCare project, implemented in five countries including Uganda and Nigeria, aimed to improve the quality of maternal care by strengthening the knowledge and skills of midwives through life-saving skills training⁹. The life-saving skills (LSS) training program provided midwives with an expanded number of skills for preventing and managing obstetric emergencies. The three-week competency-based training program includes:

1. monitoring progress of labor using the partograph;
2. preventing and treating post-partum hemorrhage;
3. managing difficult deliveries focusing on vacuum extraction;
4. hydration and rehydration;
5. preventing and managing sepsis; and
6. resuscitating the adult and the newborn.

The LSS training resulted in decreased postpartum hemorrhage, reduction of prolonged labor, improved infection control and reduction in postpartum sepsis.

b. Improving Interpersonal and Counselling Skills to foster positive client-provider interactions between the community and the health system.

c. Task shifting specifically in areas where there are few or no doctors, play a pivotal role in preventing many needless maternal deaths. Shifting tasks from one group of health workers to another who have less training but who can be trained to provide the lifesaving interventions.

Midwives and Obstetric nurses can be trained to perform emergency surgery, including cesarean section and surgical management of ruptured uterus¹⁹

The life-saving skills (LSS) training program should be introduced in areas where it is lacking and should be a continuing education project for midwives

d. Ensuring Availability of Drugs and Supplies: “Pack systems” and “emergency boxes” of supplies for treatment of obstetric complications should be developed and made readily available at the facility when needed. These include pack systems for treatment of leading causes of maternal mortality -- hemorrhage, obstructed labor, sepsis, and eclampsia. Packs for cesarean section also have been developed, which include supplies such as gauze, syringes, needles, anesthetic agents, antibiotics, intravenous fluids, and ergometrine²⁰

15.     What have we learned so far, since the Safe Motherhood Initiative was launched in 1987?

We have learned that the Safe Motherhood Initiative has implemented a variety of programs in an attempt to reduce maternal mortality worldwide. These include a range of interventions such as antenatal care, training of traditional birth attendants, provision of micronutrients, improving girl’s education to prevent maternal deaths, and empowerment of women. To this date, after almost 25 years, and despite all these efforts, maternal mortality ratios have not declined significantly.

We have also learned that EmOC is central to saving the lives of women who develop obstetric complications. Thus, it is time for the international community and governments to focus their efforts in saving women’s lives through the implementation of quality EmOC programs. Unless EmOC programs are in place, maternal mortality ratios will not decline.

References

1 WHO: Maternal mortality Fact sheet N°348 May 2012

2 Trends in Maternal Mortality: 1990 – 2010 WHO, UNICEF, UNFPA and The World Bank estimates

3 "Maternal mortality by country", UNICEF (United Nations Children?s Fund). 2002. Official Summary: The State of the World's Children 2002. New York: Oxford University Press.

4 Reference: http://www.childinfo.org/maternal_mortality.html

5 Khan, Khalid S., et al., ‘WHO Analysis of Causes of Maternal Death: A systematic review’, The Lancet, vol. 367, p. 1069, 1 April 2006.

6 Kini Nsom 2007: Delays That Cause Maternal Mortality http://www.postnewsline.com/2007

7 Rooks J, B Winikoff, and J Bruce. 1990. Technical Summary: Seminar on "Reassessment of the Concept of Reproductive Risk in Maternity Care and Family Planning Services." New York: The Population Council.

8 Prevention of Maternal Mortality (PMM) Network. 1997. Preventing Maternal Mortality through Emergency Obstetric Care SARA Issues Paper

9. Kwast B E. 1995. "Building a community-based maternity program." International Journal of Gynecology and Obstetrics 48 Supplement 1995: S67-S82

10 Monitoring Emergency Obstetric Care: A Handbook (2009), World Health Organization, UNFPA, UNICEF and AMDD)

11 Fawcus S, M Mbizvo, G Lindmark, et al. 1996. "A community-based investigation of avoidable factors for maternal mortality in Zimbabwe." Studies in Family Planning 27(6):319-327

12. Prevention of Maternal Mortality (PMM) Network. 1992. "Barriers to Treatment of Obstetric Emergencies in Rural Communities of West Africa." Studies in Family Planning. 1992. 23(5):279-291

13 Dia A, et al. 1989. Maternal Mortality in Senegal: Contributing Factors in the Health System and the Community. Draft report.

14 Sargent C. 1985. "Obstetrical choice among urban women in Benin." Social Science and Medicine. 20(3): 287-292.

15 Prevention of Maternal Mortality (PMM) Network. 1995. "Situation Analyses of Emergency Obstetric Care: Examples from Eleven Operations Research Projects in West Africa." Social Science and Medicine. 40(5) 657-667.

16 Price T G. 1984. Preliminary Report on Maternal Deaths in the South Highlands of Tanzania. Journal of Obstetrics and Gynecology of East and Central Africa. 3(103):103-110.

17 Mbaruku G and S Bergstrom. 1995. "Reducing maternal mortality in Kigoma, Tanzania." Health Policy and Planning. 10(1):71-78.

18 Oyesola R, D Shehu, A T Ikeh, and I Maru. 1996. "Improving Emergency Obstetric Care at a State Referral Hospital, Kebbi State, Nigeria." Abstracts from the PMM Results Conference, June 19-21, 1996, Accra, Ghana

19 White S, R Thorpe, and D Maine. 1987. "Emergency Obstetric Surgery Performed by Nurses in Zaire." The Lancet 2:612-613. September 12, 1987.

20 Update. 1994. Newsletter 10. Prevention of Maternal Mortality (PMM) Network.