Maternal morbidity: neglected dimension of safe motherhood in the developing world.

In safe motherhood programming in the developing world, insufficient attention has been given to maternal morbidity, which can extend well beyond childbirth. For every woman who dies of pregnancy-related causes, an estimated 20 women experience acute or chronic morbidity. Maternal morbidity adversely affects families, communities and societies. Maternal morbidity has multiple causes, with duration ranging from acute to chronic, severity ranging from transient to permanent and with a range of diagnosis and treatment options. This article addresses six selected relatively neglected aspects of maternal morbidity to illustrate the range of acute and chronic morbidities that can affect women related to pregnancy and childbearing that are prevalent in developing countries: anaemia, maternal depression, infertility, fistula, uterine rupture and scarring and genital and uterine prolapse. Based on this review, recommendations to reduce maternal morbidity include: expand the focus of safe motherhood to explicitly include morbidity; improve data on incidence and prevalence of maternal morbidity; link mortality and morbidity outcomes and programming; increase access to facility- and community-based maternal health care and reproductive health care; and address the antecedents to poor maternal health through a lifecycle approach.

Introduction

Recent analyses show that maternal mortality declined by one-third between 1990 and 2008, although roughly 350,000 women in developing countries still die annually from pregnancy-related causes (Hogan , WHO ). In programming to promote safe motherhood, less attention has been given to addressing maternal morbidity, with sequelae that can last long after a woman gives birth. For every woman who dies of pregnancy-related causes, an estimated 20 women experience acute or chronic morbidity, often with tragic consequences (Reichenheim ). The title of a recent inquiry on maternal morbidity asked if women suffering from maternal morbidity are Better off dead? (UK All Party Parliamentary Group 2009).

Maternal morbidity affects women, their families, communities and societies (National Research Council 2000). Complications force women and their families to incur costs and debt for treatment (Ronsmans 2009), and can affect women's ability to work, resulting in loss of productivity and negative outcomes for infants and children (Hoque and Powell-Jackson 2010). An analysis of the global costs of maternal disability calculated an annual cost of US$6.8 billion (Stanton 2010).

This article addresses the scope of maternal morbidity, including how it is defined and measured, and how programmes are addressing maternal morbidity. It addresses six selected relatively neglected aspects of maternal morbidity that are prevalent in developing countries: anaemia, maternal depression, infertility, fistula, uterine rupture and scarring and uterine prolapse1 to illustrate the range of acute and chronic morbidities that can affect women related to pregnancy and childbearing. This article ends with recommendations for key actions to address maternal morbidity.

Defining maternal morbidity

Maternal mortality, while a rare event, has a clear definition and can be measured. Maternal morbidity is complex, with multiple causes, duration ranging from acute to chronic, severity ranging from transient to permanent and with a range of diagnosis and treatment options. Maternal, or obstetric morbidity, defined by WHO as morbidity in a woman who has been pregnant (regardless of the site or duration of the pregnancy), from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes, is a subset of reproductive morbidity (National Research Council 2000). Morbidity can be physical or psychological and can result from direct or indirect causes.

Disability Adjusted Life Years (DALYs) measure the number of healthy life years lost due to disability or early death (Murray and Lopez 1996). For women in their reproductive years (15–44), HIV/AIDS and maternal conditions are the primary causes of both morbidity and mortality, with the highest burden in low-income countries. At the same time, mental health conditions are also a leading cause of disability and productivity loss among women (Global Health Council ND). However, calculations of DALYs related to maternal morbidity are likely to be underestimates because a number of conditions, including fistula, incontinence, uterine prolapse, menstrual disorders, non-sexually transmitted reproductive tract infections, female genital mutilation and violence that affects reproductive health, are not included in the calculation (WHO 1998, Astbury 2009).

Co-morbidities, such as poor mental health and poor reproductive health, are difficult to quantify and are not included in the calculations of DALYs. Yet, it is common for women to suffer from co-morbidities. For example, obstetric fistula can lead to infertility and depression. Post-partum interventions are often minimised as a means to fight maternal mortality (Campbell and Graham 2006), even though the risk of maternal death continues up to six months after delivery and some of the problems experienced by women persist beyond the traditional cut-off of 42 days post-partum (Filippi ).

Estimates of maternal morbidity

The true extent of maternal morbidity is not known given definitional issues and lack of data to measure its incidence and prevalence.2 Table 1 shows the best estimates available for the maternal morbidities included in this article. Although maternal morbidity is known to be underreported, these estimates3 show widespread suffering and regional disparities among the conditions. Sources of data include systematic reviews of published literature, as well as hospital- and population-based studies.

Table 1.

Estimates of incidence and prevalence of selected conditions of maternal morbidity.

Morbidity and definition	Prevalence/incidence	Source
Overall	136 million births annually	UN Population Division (2008); Filippi et al. (2006), based on WHO (2005); Say et al. (2004); and Ashford (2002).
	1.4 million women experience acute obstetric morbidity (near-miss) events9.5 million women experience other complications20 million women suffer from long-term disabilities
Anaemia	42% of pregnant women worldwide	WHO (2008), Malaria Consortium (2009) and WHO (2010)
	In sub-Saharan Africa, malaria is estimated to cause up to 400,000 cases of severe maternal anaemia per year Almost 90% of anaemic women reside in Asia or Africa
Maternal mental health Infertility	20–30% of perinatal women in developing countriesAround 186 million ever-married women ages 15–49 in the developing countries (excluding China) were infertile because of primary or secondary infertility in 2002 25% of ever-married women of reproductive age in these countries 30% of women with secondary infertility are in sub-Saharan Africa	UNFPA (2009b) Rutstein and Shah (2004)
Fistula	Global estimates vary from:	www.endfistula.org/fistula_brief.htmStanton et al. (2007)
	2 million women worldwide with 50,000–100,000 new cases annually 654,000 cases, with 262,000 of these in sub-Saharan Africa
Genital and uterine prolapse	2–20% of women of reproductive age	Columbia University (2009)
Uterine rupture	In the developed world, 1 in 1000 for scarred uteri to less than 1 in 10,000 for unscarred uteri and approximately 10 times higher in developing countries	Lombaard and Pattinson (2006)

Estimates suggest that of the 136 million women who give birth each year, around 1.4 million women experience near-miss events, 9.5 million experience other complications and 20 million suffer from long-term disabilities.4 Of the morbidities included here, maternal depression and fistula affect the largest numbers of women.

Key neglected maternal morbidities

This set of morbidities, all neglected to varying degrees, illustrates the range of problems women can face related to pregnancy and childbearing. Some are acute, while others are chronic. These morbidities have different aetiologies and some are related to the quality of care women receive during pregnancy and childbirth and others to a broader set of social, personal and other factors outside of the health system. Some can be traced to conditions that start in childhood and can create intergenerational effects.

Anaemia

Anaemia is a condition associated with an insufficient number of red blood cells or concentration of haemoglobin. The most common form is iron-deficiency anaemia, in which the body lacks sufficient iron to keep the red blood cells functioning properly (WHO 2008). Current evidence suggests that severe anaemia directly causes maternal mortality and morbidity due to poor ability to withstand the adverse effects of excessive blood loss, as well as an increased risk of infection or maternal fatigue (Sangvhi ). Anaemia is associated with increased infection, depression, fatigue and low-work productivity, as well as poor pregnancy outcomes (Girard 2010).

According to WHO (2008), 42% of pregnant women have anaemia worldwide. Half of the anaemia burden is due to iron deficiency, with estimates varying widely depending on the setting (Girard 2010). Almost 90% of anaemic women reside in Asia or Africa (WHO 2008). Steketee estimated that between 200,000 and 500,000 pregnant women in sub-Saharan Africa develop severe anaemia as a result of malaria.

The Global Burden of Disease Analysis in 2004 estimated that the prevalence of maternal anaemia could be reduced by one-third to one-half over a decade if action is taken to launch focused, large-scale programmes that are based on lessons learned from countries with successful programmes, such as Thailand and Nicaragua (Sangvhi ). Iron-folic acid supplementation during pregnancy, malaria prevention and treatment of parasites (which is safe during pregnancy) can reduce anaemia during pregnancy. Through iron-folic acid supplementation, Thailand successfully reduced the prevalence of anaemia among pregnant women from 25% in 1988 to 15% in 1997 (Winichagoon 2002 cited in Sanghvi ). Many countries do not meet current WHO standards for iron-folic acid supplementation and coverage remains low (Stoltzfus and Dreyfuss ND, Girard 2010). Programmes to prevent malaria, including increasing use of insecticide-treated bednets, will also have an effect. Reaching women during their first pregnancy is critical since anti-adhesion antibodies, which limit the accumulation of parasites in the placenta, are present ‘in pregnant women from Africa and Asia who have been pregnant on previous occasions (multigravidas), but not in those who are pregnant for the first time (primigravidas)’ (Fried ).

Integrated approaches, which have combined health systems strengthening, kitchen gardens, small animal rotating funds, community-based supplementation of children, non-pregnant and pregnant women plus fortification and nutritional education, have reduced anaemia in Ghana from 63% to 25%, in Malawi from 59% to 48%, in Senegal from 81% to 65% and in Tanzania from 87% to 73% (Girard 2010).

Maternal mental health

Mental health issues following childbirth fall into three distinct conditions: transient mood disturbance [baby blues], depression and psychotic illness (Fisher ). The most common condition is depression. UNFPA (2009b) estimates that the prevalence of depression is 20–30% among women in the perinatal period in developing countries (see Table 1). Rates of maternal depression vary widely around the world, and have been reported as 15–28% in Africa and Asia (Husain ), and 35–47% in Latin America (Wolf ).

In addition to the effects of poor mental health on women, a range of adverse infant and child outcomes have been linked to poor maternal mental health, including under-nutrition, stunting and problems with breastfeeding, behavioural problems, child temperament, childhood depression, cognitive and motor delays and low academic achievement (Wachs ). Research shows an association between maternal mental health issues and child health outcomes, independent of other variables including poverty, crowded living conditions and infectious diseases (Patel ).

Awareness of the need to focus on mental health programming in developing countries is increasing (WHO 2009). Addressing maternal mental health and depression in low-resource settings requires a tiered approach, beginning with addressing environmental stressors that increase women's vulnerability to depression, including poverty and gender inequity (Fisher ). A number of interventions have been shown to reduce the severity of maternal depression, including social support for depressed mothers or mothers at risk of depression in Taiwan, group therapy in Uganda, use of existing health mechanisms in Jamaica, and enhancing mother–infant interactions in South Africa (Wachs ). A programme in rural Pakistan, using community health workers, improved recovery rates of mothers with depression and led to better outcomes for infants (Rahman ).

Cost-effective and sustainable approaches are needed to prevent and treat mental health problems among women who experience a perinatal death and near miss-complications (Flenady and Wilson 2008, Filippi ). Fisher recommend screening for risk factors for poor reproductive mental health during perinatal care. Health providers need more training on psychosocial aspects of health, ‘the different situations, resources, demands and power relations of women and men’ (Paltiel 1993, p. 212). Patel and Kirkwood (2008) suggest examining the feasibility of placing community health worker programmes for pregnancy-related depression into Integrated Management of Childhood Illnesses (IMCI) and Maternal and Child Health (MCH) programmes.

Infertility

Infertility is considered primary if a couple has never had a child despite trying to conceive, and secondary if a couple fail to conceive after a previous pregnancy (WHO NDa). WHO considers a couple infertile if they have tried to conceive for two years through regular sexual intercourse without using contraception, the woman has not become pregnant and there is no other reason such as breastfeeding or post-partum amenorrhea. Others define infertility as one year of trying to conceive.

Depending on the definition used, estimates of global infertility worldwide vary. A study using data from 47 Demographic and Health Surveys in developing countries estimated, ‘that in 2002, more than 186 million ever-married women of reproductive age… in developing countries (excluding China) were infertile because of primary or secondary infertility’ (see Table 1). ‘This number represents more than one-fourth of the ever-married women of reproductive age in these countries’ (Rutstein and Shah 2004, p. xiii).

Fertility is highly valued in most societies, and the inability to have children, considered a form of maternal morbidity, can lead to negative social outcomes. Despite severe negative consequences for women, infertility has received insufficient attention in safe motherhood and reproductive health programmes. Infertile women face social stigma and marital instability (Fisher 2009). In Tanzania, a study found that the life circumstances of infertile women were considerably worse than circumstances of women with at least one child (Hollos and Larsen 2008).

Prevention and treatment of sexually transmitted infections (STIs) is key to preventing infertility. STIs are the most preventable cause of infertility, particularly in women (WHO NDb). Tubal infertility related to STI can be prevented through primary and secondary prevention efforts. ‘Treating “endstage” tubal infertility is very costly; thus, preventing the condition is imperative’ (Cates 2003, p. 9).

Women and men in developing countries who face infertility need information about treatment possibilities. While access to assisted reproductive technologies (ART) is expanding in developing countries, at costs far below those prevailing in the developed world, for most programmes and couples, the cost of ART remains an inhibiting factor (Vayena , Fisher 2009, WHO Bulletin 2010).

Obstetric fistula

Obstetric fistula is a medical condition that occurs as a complication of obstructed labour. The result is an opening between the bladder and the vagina or the rectum with the woman passing urine or faeces through the vagina. ‘While obstetric fistula is both preventable and treatable, once it occurs it has severe health as well as psychological and socio-economic consequences’ (Medina , p. 6). Fistula occurs almost exclusively in developing countries and affects girls and women of all ages, both at first pregnancy as well as in later pregnancies (Miller , Mehta and Bangser 2006, Ndiaye ). Worldwide prevalence estimates of obstetric fistula range from 654,000 cases to two million cases and an annual incidence of 50,000–100,000 cases (see Table 1). Stanton estimate that 262,000 of the cases of fistula are in sub-Saharan Africa.

Among the maternity morbidity conditions included in this article, fistula has received the most attention including through The Campaign to End Fistula (ND), likely due to its extreme adverse effects on women's lives. Yet, awareness of fistula remains low. At the health services level, four key prevention measures are ‘family planning, consistent and correct use of the partograph, immediate catherisation for women who experience obstructed labour and strengthening cesarean delivery services’ (Engender Health 2010, p. 32). Access to emergency obstetric care is critical. Routine collection of data on fistulas, including at health facilities providing services, is needed to aid programming. Prevention, treatment and rehabilitation services are underfunded. Social factors related to fistula, such as early marriage and child-bearing and poor nutrition, also need to be addressed.

Surgery can normally repair the injury, with success rates as high as 90% when performed by experienced surgeons, although a standard protocol for surgical interventions is needed (HERA and ICRH 2010), maintaining the skills of surgeons is critical (Arrowmith ), and many women with fistula do not have access to surgery. In some developing countries, substantial progress has been recorded: for example, in south-east Nigeria, the number of genital fistulas seen in one hospital fell from 136 cases in 1981 to 35 cases in 2005, possibly due to increased access to tertiary care and improved nutrition (Obi ).

Training of nurse midwives to perform caesarean sections has been undertaken in Mozambique, Malawi and Tanzania and is under discussion in a number of other countries, a shift that should assist in preventing fistulas (AMDD ND). In Ethiopia, health extension workers have been trained to identify fistulas so that women can access treatment [Wakabi 2008, Wude 2008, J. Ruminjo (personal communication with Jill Gay, 17 December 2010)]. Referral systems have been established in Tanzania (Bangser 2007).

Outreach campaigns, including radio programmes and community-based activities, have been conducted regarding fistula as a treatable condition in Sudan, Nigeria and other countries (Diop , UNFPA 2005, 2009a). Communities can benefit from information on the danger signs that require accessing Emergency Obstetric Care (EmOC) and transport to EmOC (Mehta and Bangser 2006, Miller ).

Once women have fistula, how best to combat dependence, stigma and social rejection are issues of great importance to the women themselves (Ndiaye ). Depression is an issue for women even post-surgery (Goh , Zheng and Anderson 2009). When surgery fails, women and their providers need counselling and support (Wude 2008). Women who have fistulas from sexual violence may have different needs than women who have fistulas due to obstetric complications (Peterman and Johnson 2009). Reintegration of women living with fistula is critical, and programmes in Tanzania, Bangladesh and Pakistan have shown some success (Bangser 2006, HERA and ICRH 2010).

Uterine rupture

Uterine rupture is a forcible tearing of the uterus, which can result in maternal death, maternal morbidity or fetal death (El Joud ). Complications related to uterine rupture, besides death, include: fever; bladder injury; wound opening; sepsis, infection carried by the bloodstream from its original site that can overwhelm the body; and the need for blood transfusions and ICU (Zeteroglu ).

Uterine rupture rates in developed countries vary from one in 1000 for scarred uteri to less than one in 10,000 unscarred uteri, with rates in developing countries approximately 10 times higher (Lombaard and Pattinson 2006). The incidence of uterine rupture is 14 times higher in women with uterine scars (El Joud ). A very low incidence of uterine rupture can be achieved when functioning maternal health systems are in place (El Joud ). A study at the University of Nigeria Teaching Hospital in Enugu found that one of 106 deliveries resulted in a uterine rupture (Ezegwui and Nwogu-Ikojo 2005). In a cohort of 20,326 pregnant women in West Africa, 25 cases of uterine rupture were identified, giving an incidence rate of 1.2 uterine ruptures per 1000 deliveries (El Joud ).

Incidence of uterine rupture is low to non-existent in countries in the Global North for women who do not have uterine scars. Timely laparotomy (incision through the abdominal wall); awareness by women of obstetric emergencies; plans to access EmOC should an emergency arise; functioning referral systems; safe caesarean sections and blood transfusions; and training to eliminate incorrect use of oxytocic drugs and fundal pressure can eliminate uterine rupture (El Joud ).

Genital and uterine prolapse

Genital prolapse occurs when a weakened pelvic musculature can no longer support the proper positioning of the vagina and uterus. Uterine prolapse is a form of genital prolapse and occurs when the uterus slips from place into the vagina. The global prevalence of genital prolapse is estimated to be 2–20% in women under age 45 (Bonetti ). A study in Nepal found that over half (57%) of those with symptoms of uterine prolapse had not had any treatment and of the 38 women advised to have an operation, only 8 did so (Kumari ). Women often do not know that treatment exists and cannot afford to pay for treatment (Bodner-Adler ).

Uterine prolapse is most commonly caused by trauma or difficulty at childbirth. Genital prolapse can also occur when women carry heavy loads, particularly post-partum (Bodner-Adler ). Prolapse can drastically affect quality of life, causing difficulty walking, sitting, lifting and squatting. Prolapse can also result in lower back pain, abdominal pain, painful intercourse, stress urinary incontinence and difficulty defecating. Surgery is needed once prolapse occurs; however, no consensus exists on the best operation, which must be tailored to the needs of the individual woman (Kumari ). Preventive solutions include: establishing regular gynaecological services in rural areas using a genital prolapse checklist; reducing women's workload post-partum; and encouraging men to takeover chores that involve heavy lifting during pregnancy and post-partum (Bonetti ).

Recommendations for key actions to address maternal morbidity

Building on the momentum started in the 1980s, attention to reducing maternal mortality has grown over the past decade as countries have sought to meet the Millennium Development Goals. Maternal morbidity, which ranges from acute to chronic, has remained a silent issue. While some programming to reduce mortality will also reduce morbidity, increased political will and resources are clearly needed to expand the scope of programmes to address the full range of maternal morbidities (Starrs and Sankore 2010).

We offer the following recommendations.

Expand the focus of safe motherhood to explicitly include morbidity

Linking safe motherhood almost exclusively to reducing maternal death related to MDG5 has conditioned policies, programmes and funding. Expanding the discourse around safe motherhood to use explicitly both the terms mortality and morbidity (or death and disability) would raise awareness of the need to address neglected morbidities, which have life-altering consequences for women and their families. Expanding the temporal scale of conditions considered related to maternal health beyond the pregnancy, labour and delivery and 42-day post-partum window would be beneficial for addressing both acute and long-term maternal morbidities.

Improve data on the incidence and prevalence of maternal morbidity

Accurate and reliable data are fundamental for programming (Graham and Hussein 2007). Reaching consensus on definitional issues and improving data collection will allow more accurate estimates of the true picture of maternal morbidity. The Child Health Epidemiology Reference Group [CHERG] (2010), studying the incidence and sequelae of maternal morbidity, notes that, ‘limited epidemiological evidence suggests that the causal pattern of morbidity is different from the causal pattern of mortality and information on morbidity could change the way interventions are prioritised in safer motherhood’ (www.cherg.org). Calls to strengthen morbidity surveillance have come from many organisations (UNICEF 1997, WHO 2009).

Link maternal mortality and morbidity outcomes and programming

Improving the quality of pregnancy and delivery care will result in reductions to both mortality and some morbidity. Reducing haemorrhage, which can lead to death, will also have an impact on anaemia and obstetric fistula. Increasing access to skilled birth attendance and EmOC will also reduce fistula. A study in Mexico found that the same cost-effective interventions which would reduce maternal mortality would reduce maternal morbidity associated with some maternal complications: increasing family planning, ensuring access to safe abortion for women electing to terminate a pregnancy and providing access to intrapartum care for all pregnant women and enhancing access to comprehensive EmOC (Hu ).

Increase access to facility- and community-based maternal health care

While reduction of maternal mortality depends on strengthening health systems to provide widespread, equitable access to EmOC and skilled birth attendance (Freedman 2007), it is becoming increasingly clear that it can also reduce maternal morbidity. Maternal morbidity can be used to audit the quality of care, understand how women experience health care services and facilities and to assess met need for critical care (Reichenheim , Ronsmans 2009). Overused practices that contribute to maternal morbidity, for example, include medically unnecessary caesarean sections (Karolinski ) and routine episiotomy.

Increasing access to and use of antenatal care could provide the opportunity to discuss childbirth planning and the danger signs in pregnancy, as well as facilitating care-seeking for obstetric complications among women with little education who are at highest risk (Roost ). Task shifting could help to reduce maternal morbidity as well as mortality, for example, by reserving specialist time for EmOC and fistula repair.

Improving outreach education and community support are also showing promising results in increasing access to care and improving health outcomes. In a systematic review of 27 studies of community-based maternal health care, Lassi et al. (2010, p. 4) found that the interventions ‘led to reductions in maternal morbidity… increased referrals to health facility for pregnancy related complications…improved the rates of early breastfeeding…and improved other mother and newborn care related outcomes'. The costs of reproductive health, maternity and child health care, including the costs of travel and service fees, inhibit women from benefiting from the continuum of care needed to prevent death and disability (Overbosch , Rahman , Lim ). Ongoing research in Sri Lanka and Kenya, measuring the costs, burden of disease and economic impact of maternal morbidity, will yield important information to support and guide maternal morbidity programming (ICRW 2010, Maternal Morbidity Project 2010).

Expand access to reproductive health care, including contraception

Reducing the number of unintended pregnancies, estimated at four in 10 of the 186 million pregnancies that occur in developing countries each year, would contribute to reducing maternal morbidity. Doubling current global investments in family planning and pregnancy-related care (from around US$11.8 billion to US$24.6 billion) would, among other outcomes, reduce the annual number of unintended pregnancies from 75 million to 22 million (Guttmacher Institute 2010). That increase in funding would also reduce unsafe abortion by almost three quarters.

Address the antecedents to poor maternal health

Poor nutrition, insufficient sanitation, lack of schooling, lack of agency in families and societies, as well as exposure to gender-based violence, take a toll on women's physical and mental well-being. Gender norms that expect women to be stoic and to suffer in silence and not reveal events at birth are harmful for women's health and, by extension, the health of their children.

Addressing a continuum of care, including taking a life cycle approach from adolescence, pregnancy, childbirth, the postnatal period and through childhood, has gained currency in safe motherhood (Tinker ). While the concept of the continuum of care is commendable, its focus on women in the post-partum period is not sufficiently long to cover longer-term or chronic morbidity. Furthermore, the continuum of care does not sufficiently address intergenerational issues, for example, the effects on infants and children whose mothers are subject to gender-based violence. Thus taking a life cycle approach starting in childhood is critical to addressing the range of morbidities women face in pregnancy and childbirth and beyond. Gender norms which disadvantage girls compared to boys in access to health services as well as nutrition can lead to malnourished adolescents who become pregnant and in turn bear disadvantaged children.

While substantial progress has been made in reducing maternal mortality, it is critical to the well-being of women to raise maternal morbidity to priority status on the global agenda and to address the key morbidities that continue to affect millions of women worldwide.