Factors Associated With Maternal Mortality And Morbidity In Developing Countries

Discuss the factors associated with maternal mortality and maternal morbidity in developing countries. What strategies can you suggest to address these problems and why?

Overview of Maternal Mortality and Morbidity in Developing Countries

Morbidity and mortality though inter-related, are two different terns. Mortality means state of being subject to death and morbidity means a condition of being diseased. The concept of maternal morbidity and mortality holds immense significance in the domain and childbirth and health of the mother (Filippi et al. 2016). According to the World Health Organisation in spite of having the high level of global focus over the maternal morbidity and mortality as an alarming public health issue, very poor knowledge is available in the domains of maternal mortality and morbidity along with the reasons underlying their occurrence (Filippi et al. 2016). The following essay aims to provide a detailed understanding about the maternal mortality and morbidity in the developing countries around the world. The essay will initiate via providing an overview of the statistics of maternal mortality and morbidity in developing countries followed at the analysis of the underlying reasons and strategies to overcome this scenario.

UNICEF India (2018) stated that maternal mortality and morbidity rate are high in the Asia and Africa in comparison to the countries in the Northern Europe and America. In relation to the maternal mortality and morbidity in Indian, one developing country in Asia, UNICEF highlighted that the maternal mortality rate has decreased from 212 deaths per 100,000 live births during the year 2007 to 167 death in the year 2013. However, the overall picture of maternal morbidity in India is still alarming. Under the global context UNICEF highlight that around the world, 800 women die each day from modifiable causes associated with pregnancy and childbirth and of these 20% accounts to Indian population. Annually it is estimated that 44,000 women die due to modifiable risk factors in pregnancy in India. Another Asian country which suffers from high rate of maternal mortality and morbidity is Afghanistan. According to the survey commissioned Afghan Ministry of Public Health and conducted by US Centres for Disease Control and prevention and UNICEF, the maternal mortality ratio of Afghanistan accounts to 1600 deaths per 100,000 live births and this highest in the world. In the most remote and in rural districts on Afghanistan, the estimate accounts for 6507 deaths per 100,000 live births. The most common cause of death includes obstructed labour especially among the young women and lack of skilled birth attendant (Britten 2017).

Figure: Maternal mortality ratio in India

Source: National Institution for Transforming India Government of India 2018

Maternal Mortality and Morbidity in India and Afghanistan

Under African context, African Population and Health Research Centre [APHRC] (2017) highlighted that in Nigeria, one out of 13 women die during labour pain or the at the time of delivery or immediately post delivery tenure. The risk is high in comparison to other parts of Africa where the ratio is 1 out of 31 child births. Nigeria accounts for about 40,000 maternal death per year which increase the overall rate of morbidity in the obstetric department and accounts for about 14% of the global maternal mortality and morbidity toll. According to APHRC (2017), Nigeria is the second largest contributor of maternal morbidity after India. 109 Nigerian women die encounters premature death from preventable causes at the time of pregnancy or during the time of delivery.

Figure: Trends in Maternal Mortality Rate per 100,000 live births from 1990 to 2015

(Source: APHRC 2017)

Caldwell (1986) highlighted that the main reasons underlying the maternal mortality and morbidity in the developing or poor countries are guided by the socio-economic factors, gaps in designing the healthcare systems, medical quotient, and reproductive factor. Other associated cause of maternal mortality and morbidity in the developing countries are guided by direct obstetric causes like hemorrhage, infection, ruptured uterus, hypertensive disorders, anemia and hepatitis. Kane (1991) also highlighted that the maternal death related to sepsis mostly encounters from the illegally induced abortion, early age pregnancy or multiple of unplanned pregnancy.

According to Mensch et al. (1993), high rate of maternal mortality in the developing countries is due to high rates of childhood marriage. Raj and Boehmer 2013 conducted a study in order to analyze the association between national rates of girl child marriage and maternal mortality and morbidity in the developing countries around the world. Raj and Boehmer 2013 mainly analyze 97 nations for which the girl marriage data was available. The regression analysis adjusted for the development countries around the world highlighted that there is significant association between the child marriage and high incidence of maternal mortality and morbidity. In relation to this analysis, Fall et al. (2015) argued that the psychological status of a teenage girl is underdevelopment to withstand the load of childbirth and this leads to internal hemorrhage and increasing the tenacity of maternal mortality.

According to Royston and Sue Armstrong (1989), unplanned family planning or conceiving within the gap of one year increases the chances of maternal mortality and thereby increasing the overall morbidity. This tendency is more prone in the countries like Afghanistan, Pakistan and Ethiopia. According to the study undertaken by Wado, Afework and Hindin (2013), unintended pregnancies and lack of use of the proper maternal healthcare services is the main reason behind the high rate of maternal morbidity and mortality in Ethiopia. Wado, Afework and Hindin (2013) mainly conducted a survey among 1370 women with recent birth in a Health and Demographic Surveillance Site (HDSS) in southwestern Ethiopia. The statistical analysis highlighted that women are of the opinion that majority of the pregnancy are unintended and this increases the complications at the time of childbirth and thereby increasing the rate of morbidity.

Maternal Mortality and Morbidity in Nigeria

According to Guerrier et al. (2013), in spite of taking considerable efforts towards reducing maternal mortality and morbidity ratio (MMR) during the tenure of 1990 to 2015 globally, a number of pregnant women still encounters death in the developing countries. It is highlighted that the pregnancy related mortality is mainly due to delays in fetching proper medical help or medical service on time or receiving the desired care on time at the time of delivery or during the gestational period. Guerrier et al. (2013) mainly conducted a study in order to determine incidence and caused of maternal mortality over a period of 8 months in the rural and secondary health care facility situated in Jahun, in the northern fringe of Nigeria. The mainly used the structure of the retrospective observational study over 41 bed in the obstetric ward during October 2010 to May 2011. The analysis of the demographic data and obstetric traits highlighted that the majority of the maternal and neonatal mortality occurred due to unbooked admissions in the hospital ward due to high labour pain during the time of delivery. Other reasons highlighted due to high incidence of maternal mortality and morbidity includes obstructed labour, hemorrhagic shock and puerperal sepsis (Guerrier et al., 2013).

Thaddeus and Maine (1994) highlighted that lack of proper healthcare access and lack of trained professionals in the healthcare units in the remote areas of the developing countries are the reason underlying the increase rate of mortality and morbidity in the developing countries. Birmeta, Dibaba and Woldeyohannes (2013) stated that rural regions of the developing countries like Ethiopia is devoid of proper healthcare clinics and training midwives to assist the women at the time of their delivery and thus increasing the morbidity and mortality of the pregnant women.

According to policy makers and the demographers, the formal schooling of the mothers even at the level of primary school is associated with the lower risk of maternal mortality and morbidity along with decreasing the risk of child mortality (Barro & Lee 2013). However, Barro and Lee (2013) highlighted that how primary level of schooling among the mothers of the developing countries is helpful in reducing the overall health of the maternal mortality and morbidity is puzzling. In order to understand the effect the mother reading and primary level education over the maternal mortality and morbidity, Smith-Greenaway (2013) conducted demographic and health survey study under Nigerian perspective. Smith-Greenaway (2013) mainly used the demographic data in order to analyse the women reading skills and literacy level in relation to maternal morbidity and mortality. The analysis of the results highlighted that is more demographic data analysis is required to be undertaken in order to understand how mother’s reading skills lowers the level of maternal and child mortality. However, the demographic analysis study conducted by Smith-Greenaway (2013) highlighted increase in the level of primary school among the mothers of the developing countries like Nigeria helps to increase the level of awareness among the expecting mother in the domain of importance of basic hygiene and accessing the service of the healthcare organization at the time of delivery and this help to reduce the vulnerability of the maternal mortality and morbidity. 

Underlying Reasons for Maternal Morbidity and Mortality in Developing Countries

Montgomery et al. (2014) are of the opinion that one of the effective way of preventing maternal mortality and morbidity in the developing countries is increase in the overall healthcare access in the remote areas along with increase in the level of pregnancy related awareness and concept of family planning. The study conducted by Moyer, Dako-Gyeke and Adanu (2013) in Sub-Saharan region revealed that facility based delivery and effective person-centred care plan for the mother at the time of pregnancy and at the time of delivery is successful in reducing the level or maternal morbidity and mortality. The government must also come forward towards increasing the overall awareness of pregnancy and the normal hygiene, lifestyle and the nutritional plan that are required to be followed at the time of pregnancy. The reports highlight that in the rural regions of the developing countries like in India, Bangladesh and in parts of Pakistan and Afghanistan; the pregnant women are forced to perform labour work and are deprived of nutritional diet. This increases the maternal mortality and morbidity rate (Islam et al. 2015). It is the duty of the government to come forward and take active initiative in designing awareness program under community health approach in order to increase the knowledge of the mass about pregnancy and the physiological needs of a woman body at the time of pregnancy. The World Health Organisation is taking active initiatives to work in association with the NGOs and the developing countries in order increase pregnancy related awareness (Montgomery et al. 2014).

Other approaches that are required to be undertaken in order to decrease the maternal mortality and morbidity in the developing countries throughout the world is reduction in the child marriage along with increase in the overall healthcare delivery services directed towards the young adults mother. The reason behind this is adolescent mothers are more vulnerable in developing complications during pregnancy and at the time of delivery and post delivery process. UNICEF supports cross-sectors initiatives in order to improve the maternal health in partnership with the organisations in the domain of nutrition and communication development. The government of India, one of the developing countries where rate death tolls of mother at the time of child birth are high is taking active initiatives towards reducing the maternal morbidity and mortality. The Indian government has launches special campaign in order to reduce the number of child marriages in the rural regions of India along with the implementation of Janai Shishu Suraksha Karyakaran scheme which provides special maternity care services to the expecting mothers in the rural areas of India (UNICEF India 2018).

Effect of Formal Schooling on Maternal Mortality and Morbidity

Conclusion

Thus from the above discussion, it can be concluded that the overall rate of the maternal mortality and morbidity is high in the developing countries. Under developing countries which top the table of the maternal mortality and morbidity include Nigeria, Afghanistan, India, Pakistan, Bangladesh and Ethiopia. Mainly the countries of Asia and Africa score high in the level of maternal mortality and morbidity. The analysis of the literature and the published governmental reports surfaced few reasons underlying high rates of mortality and morbidity in the developing countries and these reasons include teenage marriage, unplanned pregnancy, unbooked admission in the hospitals and lack of proper healthcare access. The review of the literature highlighted few strategies that can be proved to be effective in reducing the maternal mortality and morbidity rate. Effective strategies are increasing the level of literacy among the expecting mother, increasing healthcare access in the remote areas and increase in the level of awareness. Moreover, the government of these developing countries are also required to come forward and join hands with organisations like WHO and UNICEF towards developing and implementing effective prevention strategies.

According to Kuruvilla et al. (2014), decreasing maternal mortality and morbidity rate in the developing countries is the main priority in the Millennium Development Goals (MDGs). Evidence suggests that investments and interventions and enabling policies and important in order to implemented these goals in an effective manner. However, less is known regarding why few developing countries obtain faster progress in comparison to other developing countries towards reducing the maternal morbidity and mortality. Kuruvilla et al. (2014) highlighted that the success factor for Women’s and Children health studies helped to address this gap in knowledge via the use of statistical tools and econometric analysis of data from 144 developing countries for over 20 years. This analysis highlighted that there is no optimal framework for fast track recovery in some countries. The main goal for the fast track recovery can mainly be done via the implementation of the tailored made strategies and the tenacity of adapt the change by the target population. These tailored made strategies must be designed through the critical analysis of social determinants of health of that particular country. These tailored made strategies help through proper access of the social determinants of health will help to reduce the maternal along with infant mortality and morbidity among the developing countries in a robust manner. Moreover, accountability, decision-making process and stakeholder analysis must also be implemented in order to achieve the significant results on time (Kuruvilla et al. 2014).

Strategies to Address Maternal Mortality and Morbidity

References

African Population and Health Research Centre. 2017. Maternal Health in Nigeria: Facts and Figures. Access date: 7th October 2018. Retrieved from:  https://aphrc.org/wp-content/uploads/2017/06/APHRC-2017-fact-sheet-Maternal-Health-in-Nigeria-Facts-and-Figures.pdf

Barro, R.J. & Lee, J.W., 2013. A new data set of educational attainment in the world, 1950–2010. Journal of development economics, 104, pp.184-198.

Birmeta, K., Dibaba, Y. & Woldeyohannes, D., 2013. Determinants of maternal health care utilization in Holeta town, central Ethiopia. BMC health services research, 13(1), p.256.

Britten, S., 2017. Maternal mortality in Afghanistan: setting achievable targets. The Lancet, 389(10083), pp.1960-1962.

Caldwell, J.C., 1986. Routes to low mortality in poor countries. Population and development review, pp.171-220.

Fall, C.H., Sachdev, H.S., Osmond, C., Restrepo-Mendez, M.C., Victora, C., Martorell, R., Stein, A.D., Sinha, S., Tandon, N., Adair, L. & Bas, I., 2015. Association between maternal age at childbirth and child and adult outcomes in the offspring: a prospective study in five low-income and middle-income countries (COHORTS collaboration). The Lancet Global Health, 3(7), pp.e366-e377.

Filippi, V., Chou, D., Ronsmans, C., Graham, W. & Say, L., 2016. Levels and causes of maternal mortality and morbidity.

Guerrier, G., Oluyide, B., Keramarou, M & Grais, R., 2013. High maternal and neonatal mortality rates in northern Nigeria: an 8-month observational study. International journal of women's health, 5, p.495.

Islam, F., Rahman, A., Halim, A., Eriksson, C., Rahman, F. & Dalal, K., 2015. Perceptions of health care providers and patients on quality of care in maternal and neonatal health in fourteen Bangladesh government healthcare facilities: a mixed-method study. BMC health services research, 15(1), p.237.

Kane, P., 1991. Women's health: From womb to tomb. Springer.

Kuruvilla, S., Schweitzer, J., Bishai, D., Chowdhury, S., Caramani, D., Frost, L., Cortez, R., Daelmans, B., Francisco, A.D., Adam, T. & Cohen, R., 2014. Success factors for reducing maternal and child mortality. Bulletin of the World Health Organization, 92, pp.533-544.

Mensch, B., Koblinsky, M., Timyan, J. & Gay, J., 1993. The Health of Women: A Global Perspective.

Montgomery, A.L., Ram, U., Kumar, R., Jha, P. & Million Death Study Collaborators, 2014. Maternal mortality in India: causes and healthcare service use based on a nationally representative survey. PloS one, 9(1), p.e83331.

Moyer, C.A., Dako-Gyeke, P. & Adanu, R.M., 2013. Facility-based delivery and maternal and early neonatal mortality in sub-Saharan Africa: a regional review of the literature. African Journal of Reproductive Health, 17(3), pp.30-43.

National Institution for Transforming India Government of India. 2018. Maternal Mortality Ratio (MMR) (per 100000 live births). Access date: 7th October 2018. Retrieved from:  https://niti.gov.in/content/maternal-mortality-ratio-mmr-100000-live-births

Raj, A. & Boehmer, U., 2013. Girl child marriage and its association with national rates of HIV, maternal health, and infant mortality across 97 countries. Violence against women, 19(4), pp.536-551.

Royston, E., Sue Armstrong, eds.(1989). Preventing maternal deaths.

Smith-Greenaway, E., 2013. Maternal reading skills and child mortality in Nigeria: a reassessment of why education matters. Demography, 50(5), pp.1551-1561.

Thaddeus, S. & Maine, D., 1994. Too far to walk: maternal mortality in context. Social science & medicine, 38(8), pp.1091-1110.

UNICEF India. 2018. Introduction. Access date: 7th October 2018. Retrieved from: https://unicef.in/Whatwedo/1/Maternal-Health

Wado, Y.D., Afework, M.F. & Hindin, M.J., 2013. Unintended pregnancies and the use of maternal health services in southwestern Ethiopia. BMC international health and human rights, 13(1), p.36.