II
Int J Gynecol Obstet, 1992, 31: II-81 International
Federation
of Gynecology
Maternal morbidity comments
and Obstetrics
in developing
countries:
a review and
L.S. Liskin Johns Hopkins University Center ,jiw Conununicution Programs. School of’Hygiene cd
Public Hedth. 527 3. Puul Pluce, Bdtimow.
MD 21202, USA) (Received (Revised
February
26th.
1990)
and accepted June 13th, 1991)
Abstract The incidence and prevalence of postpartum maternal morbidity in developing countries are poorly understood. Methodologic problems, such as lack of standard definitions, misclassification of illnesses, use of nonrepresentative samples, and inadequate validation for selfreported data, tend to compromise existing studies. Available data suggest that serious acute illnesses are common, affecting as many as 20% of mothers who deliver in hospitals in some areas. Providing good antenatal andfamily planning services should significantly reduce acute and chronic sequelae after parturition.
Keywords: Maternal morbidity; Obstetric complications; Developing countries. Introduction
For many years maternal and child health research focused on the child, rather than the mother. Recently, however, attention has turned to the maternal risks of pregnancy and childbearing. This attention has centered largely on mortality. Global estimates suggest that every year about 500 000 women die from the complications of pregnancy and childbirth. 0020-1292/92/$05.00 0 1992 International
Federation
Published and Printed in Ireland
of Gynecology
and Obstetrics
Unfortunately, mortality statistics only tell half the story. The incidence of maternal morbidity - both short- and longterm - is unknown. The most commonly quoted estimate - 16 episodes of illness for every maternal death - is based on a small study (published in 1980) of about 270 women in one Indian village [20]. That this document represents a major source of information on maternal morbidity is a clear indication of the need for more intensive research. In developing countries community surveys are the usual sources of information on morbidity, but these instruments rarely include questions on pregnancy. Most have focused on childhood conditions and infectious diseases among adults. Hospital studies have also been published, but because relatively few women in developing countries deliver their infants in hospitals, these results most likely are not representative of the population. Moreover, hospital studies shed light only on the acute complications of pregnancy. In contrast, longterm consequences of pregnancy are not considered by hospital studies and, indeed are missing from almost all research. Accurately defining maternal morbidity is one of the major problems of research directed toward pregnancy-related illness. Misclassifications are common. Many condi-
78
L&kin
tions that are obstetric in origin, such as ectopic pregnancy or vaginal fistulas, are categorized as gynecologic problems. Illnesses are variously and inconsistently categorized as conditions, complications, or complaints. Definitions and terminology for specific illnesses may vary. For example, some authors describe all hypertension in pregnancy as toxemia; others differentiate between preeclampsia and eclampsia. Specific diagnostic criteria are only rarely provided. Vague terminology for some illnesses, for example, problems with lochia, is common. International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD) classifications are used in some but not all studies. Perceptions of what constitutes morbidity vary. Research to date has focused on complications that are measurable and potentially life-threatening, such as hypertension or vaginal bleeding. The so-called minor complaints of pregnancy - nausea and vomiting, backache, fatigue and sleeplessness - are only rarely addressed even though these conditions may significantly impair women’s wellbeing and their ability to work. Conversely, women may not view some complications as illness. Swelling of the hands and face is an ominous sign to health workers, but few women will regard this as illness. The majority of women in the world go through pregnancy and childbirth without any assistance from formally trained health care providers. Under these circumstances, most illnesses, like most deaths, fail to attract the attention of health care providers. If, however, the often quoted estimate of maternal morbidity - 16 illnesses for every death - is correct, then roughly 8 million women experience nonfatal pregnancy-related complications every year. Such a large burden of illness - much of it preventable - calls for immediate attention.
world. Published reports may contain ascertainment bias in that they represent select populations of women who received antenatal care. For example, one retrospective community survey in two Chinese communities estimated the prevalence of pregnancy-related illness in 917 women [42]. About 37% of the women experienced some illness during pregnancy; 21% had difficulties during labor; and 6% had postpartum complications. The most common antenatal conditions were preeclampsia and anemia. Almost one in every five women was anemic. Some 10% needed cesarean sections. Hemorrhage was the most frequent complication in the puerperium. It is highly unlikely that this study is representative of women’s experience in other developing countries. Probably all the women in these two communes received antenatal care, and apparently all gave birth in health facilities. Whereas over 70% of the women were primigravidas, most were in their early 20s the safest age to give birth. Thus, reported complication rates and serious complication rates may be low. In other countries, particularly where women give birth at very young ages, where multiparity and grand multiparity are the norm, and where antenatal care is limited, morbidity is, in all likelihood, more common. It is unfortunate that hospital studies are the major sources of information from many locations. For example, one of the largest hospitals studies, in Zaria, Nigeria, reports a high frequency of complications, particularly among unbooked women - those who received no antenatal care. With the exception of preeclampsia, various complications were two to five times more common among unbooked women than women who received antenatal care (see Table 1). Findings such as these are the rule, rather than the exception.
Prevalence of pregnancy-related
Incidence and prevalence of specific illnesses
illness
The prevalence of pregnancy-related illness has received little attention in the developing
Pregnancy-related illness can be grouped into several categories: (1) short-term, acute
Muternul
Table I.
Selected obstetric complications
Complications
Disproportion prolonged
and
in Ahmadu
Bello University
Hospital,
Zaria.
morbidity
Nigeria,
in dadoping
1976-1979,
Booked women
Unbooked
with complications
with complications
by booking
No.
‘%I
No.
‘%I
status.
827
5.6
2.054
26.9 6.4
labor
Preeclampsia
888
6.0
490
135
0.9
389
5.1
228
1.5
547
7.2 2.3
Antepartum
hemorrhage
rupture
Postpartum Retained
79
women
Eclampsia Uterine
countries
hemorrhage
placenta
Cesarean section .%urce: Harrison
26
0.2
177
255
1.7
390
5.1
26
0.2
889
I I.6
941
6.4
1,097
14.3
1985 [30].
complications directly related to pregnancy and the puerperium such as hemorrhage, obstructed labor, and infection; (2) chronic complications such as vaginal fistulas, that may occur at the time of labor and delivery or uterine prolapse that may occur many years later; and (3) associated illnesses - malaria and non-A, non-B hepatitis - that either occur or progress rapidly because of reduced immunity in pregnancy. While scant information on incidence is available for most of these conditions, data on longterm complications are particularly sparse. Short-term complications Pregnancy-induced hypertension. Assessing
the incidence of preeclampsia is particularly difficult because definitions of the disorder and case identification vary widely. A recent WHO collaborative study used a standardized diagnostic protocol to evaluate the incidence and eclampsia among of preeclampsia primigravidas in four Asian countries [78]. Clinical diagnosis of hypertensive disorders of pregnancy ranged from 1% in Vietnam and Thailand to 5% in Burma and 31% in China. Although the incidence of eclampsia was much lower than that of preeclampsia, particularly in China, differences between the four populations were statistically significant. The
lowest rate, 0.1X, was found in China and the highest, 0.9% in Thailand. In China, many more women with preeclampsia received medical treatment than in other countries. This may explain why the rate of eclampsia is lowest (Golding, personal communication). Hospital studies reporting the prevalence of preeclampsia also vary widely. Rates of eclampsia, on the other hand, show less variation - one to two cases per 1000 deliveries in Tanzania [5], India [lo], and Kenya [9], and 4-5 per 1000 in Jamaica [32] and Ilorin, Nigeria [l]. Considerably higher rates have been reported - 23 cases per 1000 pregnancies in Zaria, Nigeria [30] and 19 per 1000 deliveries in southeast Turkey [68]. Like many other complications, eclampsia occurs most often among the youngest mothers. In a Tanzanian study of 2800 primigravidas, almost three-quarters of the 36 cases of eclampsia occurred among women under 20 [4]. Similarly, among Nigerian primigravidas, girls younger than 15 were six times as likely to develop eclampsia as women aged 20-24 [30]. Ectopic pregnancy. An ectopic pregnancy is one of the most dangerous complications of pregnancy. Mortality is high because of heavy internal bleeding, frequent misdiagnosis and delay of appropriate treatment. In the United
80
Liskin
Table 2.
Rates of ectopic pregnancy,
Region and
Date
country
hospital studies 1963-1984.
No. of
Per 1000
ectopic
deliveries
Reference
pregnancies
Africa Kenya
1967-1968
119
7.6
I461
Mozambique
1987-1988
103
8.3
I151
Nigeria
1978-1979
100
23.2
Nigeria
1977-1987
I98
4.8’
1441
South Africa
1983-1984
100
15.2”
[431
Tanzania
1971-1977
251
10.3
151
Asia India
1964-1973
500
4.4
[361
Singapore
1975-1980
I21
161
Singapore
I972-
I48
3.7 2.9
75
6.2
I311
I977
[581
[lgl
Middle East Jordan
1976-1982
1Rate per 1000 live births.
States, in 1985, ectopic pregnancy accounted for less than 2% of all pregnancies but caused 11% of all maternal deaths [72]. The incidence of ectopic pregnancy in the United States and Europe has increased markedly since the 1970s [ 12,40,45,49,67, 71,771. In the United States, reported cases increased from 17 800 in 1970 to 78 400 in 1985. The rate per 1000 pregnancies rose threefold, from 4.5 to 15.2 [7,23,40]. Much less information is available in developing countries (see Table 2). Hospital studies in African countries document a range of rates from 4.78 to 23.2 ectopic pregnancies for every 1000 deliveries. In one Nigerian hospital ectopic pregnancy accounted for 6% of all gynecological admissions and 15% of all emergency admissions [58]. Postpartum infection. Postpartum and postabortion infection are common in developing countries. In Nigeria and India from 2 to 5% of newly delivered women develop genital or urinary tract infection [30,36]. In a Kenya study, by the 7th day postpartum, 20% of women had upper genital
tract infections [63]. In contrast, only 1% of the women in two Chinese communes where antenatal care was common developed infection after delivery [42]. Complications during labor - obstruction, prolonged labor, premature rupture of membranes, as well as any kind of surgical delivery or use of instruments - increase the risk of infection after the delivery. Sexually transmitted diseases (STDs), particularly gonorrhea and chlamydial infection, also are important risk factors. In the Kenyan study cited above, women with gonococcal infections had a fourfold risk of developing upper genital tract infection, and women with chlamydial infection faced a two-fold risk [63]. The prevalence of gonococcal and chlamydial infections was 7% and 23% respectively [63]. Other studies confirm the high rate of STDs in pregnant woman in Africa. In various countries from 3 to 22% of pregnant and postpartum women have gonococcal infections and from 5 to 9% chlamydial infections [41]. Rates are lower in Asia and in America [761.
Murernul
Table 3.
Prevalence
Region and country
of obstructed
labor,
hospital
nmrhidity
in developing
coun!ries
8I
studies.
Date
No. of cases of obstructed labor
1%)of deliveries
Reference
1976-1979 1984-1986 1981-1982
1239” 740 319
5.5 19.9 17.8
1301 1251 [341
1976-1980 1979-1980 1977
1494 1494 I28
10.2 11.5 2.9
[l II 1131
1101
224
II.3
1321
Africa Nigeria Zaire Zaire Asia Bangladesh Bangladesh India Caribbean l966- I969
Jamaica “Prolonged
labor
Obstructed labor. A large proportion of hospital deliveries, particularly in Africa, are complicated by obstructed labor (see Table 3). Several risk factors for obstructed labor have been documented - young age, primiparity, and short stature. In Zaria, Nigeria, women younger than I5 are three times as likely to experience disproportion and more than two times as likely to labor more than 24 h than women age 20-24 [30]. In Sierra Leone, 13% of women shorter than 5 ft required cesarean section for disproportion compared with only 4% of taller women [2]. Several conditions prevalent in developing countries - poor nutrition, young age at marriage, and early childbearing - together lead to difficult labor and increased risks of postpartum infection and longterm complications. Uterine rupture. Rupture of the uterus is a fairly frequent and often fatal complication of labor and delivery in developing countries. Reports from African hospitals show rates as high as 11 cases of uterine rupture per 1000 deliveries (see Table 4). Mortality is high and ranges from 9 to 42%. Declining incidences of fatality rates of uterine rupture have been
reported in Cameroon [53], Guinea [8] and South Africa [39]. Improvements in obstetric care, particularly better monitoring of labor with partograms, and increased availability of maternity services account for this decline [39,53]. Uterine rupture often involves other injuries to pelvic organs, particularly the bladder. In one survey of 129 cases of uterine rupture, 15% of women experienced rupture of the bladder [39]. Vesicovaginal fistula also occurs but less frequently. After hysterectomy or surgical repair of the uterus, infection and other complications are common. In one Iranian study, the average hospital stay for surviving patients was 15.5 days [61]. Most uterine ruptures are caused by cephalopelvic disproportion and/or obstructed labor. However, spontaneous ruptures occurred in 20-75% of cases in the studies cited in Table 4. Rupture of a cesarean section scar is reported in 20-25% of cases in most studies. A surprisingly large percentage of ruptures (from 3 to 22%) is caused by interventions of health workers or traditional birth attendants. Use of forceps, internal verRevielc
Liskin
82
Table 4.
Prevalence of uterine rupture
Region and
Date
country
and case-fatality
rates, selected hospitals studies. 1952-1983.
No. of
Rate per
‘%I
cases
1000
died
Reference
deliveries
Africa
l967-1974a
126
2.6
Nigeria
1965-1972
I44
8.9
Nigeria
1975-1986
227
6.
South Africa
1980-1983
129
South Africa
Mid-1970s
I.1 2.7
South Africa
1968-1982
89
I.1
Tanzania
1971-1977
83
3.4
Uganda
I952-
I71
10.7
Zambia
1958-1978
I05
6.7
9 27 0 I9 20 42 l4h 20 8 8 3 12 6 I2 37 28
Cameroon
1973-1976
70
1.9
Guinea
1986-1988
122
I.8
Kenya
1975
I8
4.2
Malawi
1977
I05
2.5
Nigeria
1978-1983
65
10.8
Nigeria
1974-1980
106
6.67
Nigeria
1976-1979”
203
9.0
I958
I
1531
I81 1751 1161 I221 1481 1301 I541 1281 1371 1391 1731 151 [651 1331
Asia ml Pacific India
1964-1973
106
0.9c
22
1361
India
1953-1959
I64
2.1
II
1381
Papua New Guinea
I964-
45
7.5e
29
1171
I973
Middle East aod North Africa Libya
1977-1980
96
I.7
5
HI
Iran
1967-1977
64
1.4
9
1611
Israel
1960-1975
12
0.5
0
1261
Jordan
1957-1965
I04
4.2
37
I31
“Both series from Ahmadu ‘All
Bello University,
deaths among unbooked
Zaria.
Nigeria.
women.
CRate per 1000 live births. ‘Rate
per 1000 confinements.
sion of the fetus, craniotomy, and particularly improper use of oxytocin are the procedures most often associated with uterine rupture. Several traditional birth practices also have been implicated. In Uganda and Nigeria, for example, herbal medicines used by traditional birth attendants are reported to have oxytocic properties [65]. Also, packing the vagina with herbs can cause severe swelling of the cervix and vaginal stenosis, thus prolonging labor and increasing the risk of rupture [22]. Other practices to speed delivery such as pushing or Inr J Gynecol Obstet 37
standing on the abdomen and turning babies in the breech position also may rupture the uterus [53]. It is not clear how common these practices are, however. Longterm complications Uterine prolapse. Women with prolapse ex-
perience a variety of symptoms ranging from mild to severe. In one Nigerian survey of 278 women with second- or third-degree prolapse, about one-third reported difficulties with urination - pain, stress incontinence, and fre-
Table 5.
Percentage of women with uterine prolapse, by parity. WHO
Country
studies of family formation
patterns and health.
1976-1981.
No. of
‘%fwith
‘% of
‘%I of women
sample
women
prolapse
women
para 7+
population
examined
para
with prolapse
Location
of
l-2
with
prolapse
Colombia
Pakistan
Old urban zone
1063
a
2
25
Newly settled zone
1147
19
5
38
809
25
Semi-urban Urban
Philippines
Syria
Source: Omran
area
area
II42
II
II
37
6
I4
Rural area
1484
6
2
IS
Urban
1434
9
4
I5
IO
5
I3
6
IO
area
Damascus
1214
Sweidi
III6
3
Aleppo
I394
8
and Standley
1981 [56]. Omran
7
et al. 1976 [57]
quency. Backache and a sensation of pelvic pressure were also common. Other symptoms included constipation and pain on defecation [59]. When prolapse occurs during pregnancy or labor, women face increased risks of spontaneous abortion, retention of urine, urinary tract infection and premature labor [19,55]. Information on uterine prolapse in developing countries is scarce. The WHO studies on Family Formation and Health in Colombia, Pakistan, the Philippines, and Syria indicate that the condition is fairly common, affecting from 3 to 25% of women under 45 (see Table 5). Prevalence increases with age and parity. In most countries women with 7 or more children were two to seven times as likely to have uterine prolapse as women with one or two children. There are scattered reports on prolapse from other countries: One Indian hospital admitted a pregnant woman with uterine prolapse for every 572 obstetric cases. Repair of prolapse accounted for 75% of the major gynecologic operations in this hospital [ 191. A much lower rate was reported in a Nigerian hospital - one case for every 4700 pregnancies
[55]. In Sao Paulo, Brazil, a gynecological screening program for outpatients attending the hospital clinic with nongynecologic complaints found a rate of 40.4 per 1000 cases of genital dystopia, that is rectocele, cystocele, perineal rupture, or uterine prolapse [62]. Where marriage and childbearing begin early, prolapse may affect many younger women. In a series of 278 cases in northern Nigeria, 29% of women were younger than 30 [59]. In the WHO studies on Family Formation Patterns and Health from 2 to 10% of women younger than 25 were diagnosed with prolapse. Vaginal fistulas. How frequently Iistulas occur is unknown. In hospital studies in several Nigerian cities less than 1% of all deliveries were complicated by fistula [22,28]. It is likely that the condition is much more prevalent, however. In Ethiopia an estimated 1000 cases occur every year, and a small hospital has been built exclusively for fistula repair [29]. In Sudan 122 cases were treated at Khartoum Hospital in 20 months, comprising 16% of all major gynecological conditions [52]. Obstructed labor, particularly from ReriL,U
84
Liskin
cephalopelvic disproportion, causes most Iistulas. Young primiparous women are at greatest risk. In a study of 1443 Nigerian cases 52% of women were pregnant for the first time, and over one-third were 16 or younger. The traditional practice of cutting the vaginas of very young girls to facilitate sexual intercourse or childbirth - gishiri cuts - may cause listulas in young girls [70]. This practice, as well as uterine rupture or surgery, causes fistulas in older women. Fistulas are successfully closed by surgery in about 70-80% of first operations [24,35,74]. Stenosis of the vagina may occur, however, making intercourse painful or impossible. Women who became pregnant subsequently are at increased risk of urinary tract infections and, because they often must undergo cesarean section, are at greater risk of complications during delivery and in the puerperium [30,60]. One study reports a higher rate of spontaneous abortion after Iistula repair [47]. Fistulas reopened after childbirth in 15% of women, according to one small Nigerian study [24]. Access to and better use of health services will prevent almost all cases of fistulas. Data from Zaria, Nigeria, suggest that as the obstetric services of the major hospital in the area became better known and more women came for antenatal care and delivery, the incidence of fistulas declined. Between 1970 and 1978 the number of patients delivering in the hospital increased four-fold. The number of cases of fistula doubled, but the number coming from within 50 km of Zaria decreased steadily. By 1978 not one listula patient came from Zaria. The number of cases from areas farther away increased sharply [69]. Methodology
Measuring the extent of maternal morbidity is the first step to developing appropriate health interventions. It is not clear, however, which methodology is most appropriate for studying the short- or longterm risks of pregnancy. Three important issues, common
to all research on morbidity are: defining the morbidities to be studied, determining the appropriate population and validating selfreported information. Recent articles [14,66] have described the difficulties of studying maternal mortality. Studying morbidity involves many of the same problems and more. A maternal death is dramatic and unambiguous. Morbidity often is neither, although some illnesses - eclamptic fits for example - are obvious and unmistakable. As noted above, case identification and diagnosis of some maternal illnesses vary widely. Accurately estimating edema or amount of blood loss after delivery is difficult. Also, some conditions such as uterine prolapse are obvious on physical examination but in fact may cause relatively few symptoms and so will be underreported by women. Finally, some conditions have multiple causes and cannot be directly attributed to pregnancy. Secondary infertility, for example, is caused by sexually transmitted diseases as well as by postpartum infection. Obtaining a representative sample of the population and an accurate estimate of the incidence of morbidity in a community is not possible with in-hospital studies because many women deliver at home. Community- or population-based surveys of women are more representative, however, but not without problems. By definition, surveys exclude women who have died from pregnancy-related complications and thus may underestimate many conditions, and particularly those like eclampsia that often are fatal. To give the broadest possible picture of maternal morbidity in developing countries community surveys should involve multiple countries, geographic regions, and racial, religious and ethnic groups. This may shed some light on several unanswered questions about risk factors. A third major problem with morbidity surveys -prospective or retrospective - is validating self-reported information. Crosssectional studies result in underreporting and overreporting of illness. Retrospective survey
Muternul
data on pregnancy-related illnesses may be subject to recall bias. Women who have given birth to healthy children may be less likely to remember complications during pregnancy than women whose children died. Whether the woman wanted her child and how she feels about him/her also may bias her memory of pregnancy. The time between the pregnancy and the survey also affects recall. A study in rural Senegal on causes of death among children found that parents gave the most complete information on duration of illness and specific symptoms between 3 and 9 months after death [27]. It is not clear whether this finding can be applied to surveys of women themselves, however. Probably the best way to overcome these difficulties is to combine different sources of information. Studies of maternal mortality using a variety of sources - hospital records and interviews with health workers, TBAs and family members - have produced more information on maternal deaths than any one source alone. Similarly, morbidity surveys plus hospital records give a better estimate of the numbers of women who experience any complication, the types of complication and the major risk factors for serious morbidity and death. Neither community surveys nor hospital studies give a complete picture of the true burden of maternal morbidity or mortality to women, to their families and to their communities. How can this be measured? Researchers from WHO and the Kaiser Foundation have developed a method for assessing the health impact of different diseases in developing countries. This method uses information on incidence rates, case-fatality rates, the extent and duration of disability from various diseases, and life expectancy to measure the number of healthy days of life through illness, disability and death [50]. When the method was used in Ghana, complications of pregnancy ranked sixteenth among other conditions in the number of days of healthy life lost. This method is child-oriented, however, because it ranks individuals in direct proportion to their
morbidity
in dewloping
countric~s
85
life expectancy at age of onset of illness. Thus the death of a child is regarded as costing the community more than the death of an adult. This approach also ignores the impact of death or disability of an adult, particularly a pregnant woman, on the life expectancy of her dependents. A different kind of methodology is needed to assess more accurately the true cost to society of maternal morbidity and mortality. Without accurate information effective prevention strategies cannot be developed. Nor is it likely that the needed resources will be allocated to fund these strategies and to shift the focus of research to a more even balance between mother and child. The research on maternal morbidity is just beginning. While the full picture is still incomplete, existing studies clearly show that pregnancy-related illnesses exact a heavy toll on women’s lives at the time of childbirth and for years afterwards. The loss to women, to their families and to their communities has yet to be calculated. More tragic still, is that much of this illness is preventable. Good antenatal care, emergency transport services, education, and above all, family planning services to prevent high risk births can markedly reduce the incidence and prevalence of maternal morbidity. Developing these services and minimizing short- and longterm maternal illnesses are critical challenges for health professionals in the 1990s. References Adetoro
00:
The pattern
of llorin Teaching
of eclampsia at the University
Hospital (UITH)
Ilorin.
Nigeria.
Int J
Gynecol Obstet 31: 221, 1990. Aitken
IW.
Walls B: Maternal
disproportion Akasheh
F: Rupture
of rupture. Arkutu
height and cephalopelvic
in Sierra Leone. Trop
Dot
16: 132. 1986.
of the uterus: analysis of 104 cases
Am J Obstet Gynecol
101: 406.
1968.
AA: A Clinical study of maternal age and parturi-
tion in 2791 Tanzanian
primiparae.
Int J Gynecol
Obstet
16: 20. 1978. Armon
PJ: Maternal
Tanzania.
Trans
Atputharajah aetiological Gynecol
deaths in the Kilimanjaro
R Sot Trop V.
factors
Tubal
pregnancy:
in
cases. Singapore
13:. 78, 1982.
I I7
region of
Med Hyg 73: 284. 1979. a
review
of
J Obstet
86
Liskin
7
Atrash HK. Hughes JM, Hogue CJR: Ectopic pregnancy in the United States. 1970-1983. Morbid Mortal 35: 2955. 1986.
8
Balde MD, Bastert G: Decrease in uterine rupture in Conakry. Guinea by improvments in transfer management. Int J Gynecol Obstet 31: 21. 1990. Bansal YP: Pre-eclampsia/eclampsia: a profile from Pum-
9
IO
II
12 13
14 I5
I6 I7 I8 I9 20
21 22 23
24
wani Maternity Hospital. Nairobi, Kenya. East Afr Med J 62: 691. 1985. Basu S: Maternity care in India - an analysis of obstetric deliveries in selected hospitals. In: India Fertility Research Programme (IFRP). 5th contributors conference. 16 p. Calcutta, IFRP. 1977. Begum SF, Nahar K. Jahan FA. Khan AR: A comparative study of the pattern of maternity care services in different hospitals and clinics in Bangladesh. Presented at the 8th Asian and Oceanic Congress of Obstetrics and Gynaecology. October 25-31. 1981, 16 p. Beral V: An epidemioiological study of recent trends in ectopic pregnancy. Br J Obstet Gynaecol 82: 775. 1975. Bhuiyan AB. Ahmed G, Rahman S: Maternity cases at Rangput Medical College Hospital. In: Bangladesh Fertility Research Programme (BFRP). 5th ontributors
27
deaths using a standarized questionnaire: a Senegal. Liege, Belgium and Siena. Italy. Union for the Scientific Study of Population of Statistics, University of Siena, 1986. 41 28 29
30
31 32
33
onference. Dacca. Bangladesh. December 13. 1980. Dacca. Bangladesh, BFRP. 1981. pp 57-68. Boerma JT: Levels of maternal mortality in developing countries, Stud Fam Plann 18: 213. 1987.
34
Bugalho A. Strolego F. Pregazzi R, Osman N, Ching C: Extrauterine pregnancy in Mozambique. Int J Gynecol Obstet 34: 239. 1991. Bullough CHW: Analysis of maternal deaths in the cen-
35
tral region of Malawi. East Afr Med J 58: 25, 1981. Campbell GR: Maternal mortality at Garoka Base Hospital. Papua New Guinea Med J 17: 335. 1974. Chew SY: A 6 year review of ectopic pregnancy. Singapore Med J 20: 395. 1979. Das RK: Genital prolapse in pregnancy and labor. Int Surg 56: 260. 1971. Datta KK. Sharma RS. Razack PMA. Ghosh TK. Arora RR: Morbidity pattern amongst rural pregnant women in - a cohort study. Health Popul Alwar. Rajasthan Perspect Issues 3: 282. 1980. Eden RD. Parker RT, Gall SA: Rupture of the pregnant uterus: a 53-year review. Obstet Gynecol 68: 671. 1986. Elkins T. Onwuka E, Stovall T. Hagood M. Osborn D: Uterine rupture in Nigeria. J Reprod Med 30: 195. 1985. Ellenbrock T. Atrash HK, Hogue CJR. Hughes JM: Ectopic pregnancy mortality in the United States, 1979-1982. Morbid Mortal 36: 13. 1987. Evoh NJ. Akinla 0: Reproductive performance alter the repair of obstetric vescio-vaginal fistulae. Ann Clin Res
36
37
38 39 40
41
42
IO: 303. 1978. 25
26
I: The grand mutlipara - is it a problem? A review of 5785 cases. Int J Gynecol Obstet 23: 321. 1985. Garenne M. Fontaine 0: Assessing probable causes of
Family Health International monitoring: Karawa health Triangle Park, North Carolina,
(FHI): Pregnancy care zone. Zaire. Research FHI. 1988. I51 pp.
43
Fuchs K. Peretz BA. Marcovici
R, Paldi E, Timor-tritsh.
44
study in rural International and Institute p.
Groen GP: Uterine rupture in rural Nigeria: review of 144 cases. Obstet Gynecol 44: 682. 1974. Hamlin RHJ. Nicholson EC: Experiences in the treatment of 600 vaginal fistulas and in the management of 80 labours which have followed the repair of these injuries. Ethiopian Med J 4: 189, 1965. Harrison KA: Child-bearing, health and social priorities: a survey of 22.774 consecutive hospital births in Zaria. northern Nigeria. Br J Obstet Gynaecol YZ(supp/ 5): I. 1985. Hasan AA: Ectopic pregnancy: a seven-year survey. Eur J Obstet Gynecol Reprod Biol 16: 237, 1983. Hay DM, Boyd JJ: A study of the obstetric performance of the adolescent Jamaican primigravida. Am J Obstet Gynecol 116: 34. 1973. Heij HA. Te Velde ER. Cairns JM: The treatment of rupture of the pregnant uterus, analysis of 93 cases treated in a rural hospital in Zambia. Int J Gynecol Obstet 22: 415. 1984. Janowitz B. Lewis J, Burton N. Lamptey P. eds: Reproductive Health in Africa: Issues and Options. Research Triangle Park. North Carolina. Family Health Institute. 1984. 69 p. Kelly J: Vesicovaginal tistulae. Br J Urol 5I: 208. Konar M. Sikdar K, Basak S. Lahiri D: Maternal mortality: ten years’ survey in Eden Hospital. J Indian Med Assoc 75: 45. 1980. Konje JC. Odukoya OA. Lddipo OA: Ruptured uterus in lbadan - A twelve year review. Int J Gynecol Obstet 32: 207. 1990. Krishna Menon MK: Rupture of the uterus: a review of I64 cases. J Obstet Gynaecol Br Emp 6Y: 18. 1962. Ldchman E. Moodley J. Pitsoe SB. Philpott RH: Rupture of the gravid uterus. South Afr Med J 67: 333. 1985. Lawson HW. Atrdsh HK. Saftlas AF. Franks AL. Finch EL, Hughes JM: Ectopic pregnancy surveillance, United States, 1970-1985. Morbid Mortal Weekly Rep 37: 9. 1988. Lettenmaier C. Liskin L, Church C. Harris J: Mothers’ Lives Matter: Maternal Health in the Community. Population Reports. Series L. No. 7. Baltimore, Johns Hopkins University, Population Information Program. 1988, 40 p. Li BY, Dong A-M. Zhuo JR: Outcomes of pregnancy in Hong-qiao and Qi-yi communes. Am J Pub1 Health 72(Suppl 9): 30. 1982. Lindow SW, Moore PJ: Ectopic pregnancy: analysis of I00 cases. Int J Gynecol Obstet 27: 371, 1988. Makinde 00. Ogunniyi SO: Ectopic pregnancy in a defin-
45
46 41
48 49
50
51 52 53 54 55
56
51
58 59
60
61 62
ed Nigerian population. Int J Gynecol Obstet 33: 239, 1990. Makinen Jl. Erkkola RU, Laippala PJ: Causes of the increase in the incidence of ectopic pregnancy: a study on 1017 patients from 1966 to 1985 in Turku. Finland. Am J Obstet Gynecol 160: 642, 1989. Maley A. Auma S: Ectopic pregnancy in Nairobi. Kenya. Scot Med J 15: 172. 1970. Mati JKG: Vescicovaginal listula. In: Reproductive Health in Africa (eds JKG Mati, OA Ladipo). pp I81 - 191. Baltimore, Johns Hopkins Program for International Education in Gynecology and Obstetrics. 1984. Megafu U: Factors influencing maternal survival in ruptured uterus. Int J Gynecol Obstet 23: 441. 1985. Meirik 0: Ectopic pregnancy during 1961-78 in Uppsala County. Sweden: impact of demographic factors on overall incidence. Acta Obstet Stand 60: 545. I98 I. Morrow RH. Smith PG. Nimo KP: A quantitative method of assessing the health impact of different diseases in less developed countries, July 1980, I8 pp (unpublished). Murphy M: Social consequences of vesico-vaginal listula in northern Nigeria. J Biosoc Sci 13: 139, 1981. Mustafa AZ, Rushwan HME: fistulae in the Sudan. J Obstet Nasah BT, Drouin P: Review uterus in Cemeroun. Trop Dot
Acquired genito-urinary Gynaecol 78: 1039. 1971. of 70 cases of ruptured 8: 127. 1978.
Obayemi TOB: Maternal mortality in rupture of the iterus. Nigerian Med J 8: 433. 1978. Ogunbode 0, Aimakhu VE: Uterine prolapse during pregnancy in Ibadan. Am J Obstet Gynecol 116: 622. 1973. Omran AR, Standley CC eds: Family formation patterns and health - further studies: an international collaborative study in Colombia, Egypt, Pakistan, and the Syrian Arab Republic. Geneva, World Health Organization, 1981. 464 pp. Omran AR, Standley CC, Azar JE. Bertan M. Guzman V. Nahapetian V, Pisharoti KA: Family Formation Patterns and Health. Geneva, World Health Organization. 1976. 562 pp. Oronsaye AU. Odiase Gl: Incidence of ectopic pregnancy in Benin City, Nigeria. Trop Dot II: 160. 1981. Otubu JA, Ezem BU: Genital prolapse in the Hausa/Fulani of northern Nigeria. East Afr Med J SY: 605. 1982. Otubu JA. Kumi GO, Ezem BU: Pregnancy and delivery after successful repair of vesicovaginal listula. Int J Gynecol Obstet 20: 163, 1982. Paydar JA. Hassanzadeh A: Rupture of the uterus. Int J Gynecol Obstet IS: 405, 1978. Pinotti JA, Brenelli HB. Moragues JD. Pastene LL. Ramos RSB, Barini R. Da Silva Alves C. Stano MT, Bigatti LE: Preventive obstetrics and gynecology program: pilot plan for integrated medical acre. Bull Pan American
Health
Organization
1.5: 104. 1981.
63
64
65 66 67
68
69 70 71
72
73 74
75 76
77
78
Plummer FA, Laga M, Brunham RC. Piot P, Ronald AR. Bhullar V, Mati JY. Ndinya-Achila JO, Cheang M. Nsanze H: Postpartum upper genital tract infections in Nairobi, Kenya: epidemiology, etiology, and risk factors. J Infect Dis 156: 92. 1987. Rahman J. Sibai MH Al-, Rahman MS: Rupture of the uterus in labor: a review of 96 cases. Acta Obstet Gynecol Stand 64; 31 I. 1985. Rendle-Short CW: Rupture of the gravid uterus in Uganda. Am J Obstet Gynecol 79:. I 114. 1960. Royston E, Lopez AD: On the assessment of maternal morbidity. World Health Statist Q 40: 214. 1987. Sivin I: IUD-associated ectopic pregnancies. 1974 to 1984. In PRFR Series on Fertility Regulation (eds GI Zatuchni, A Goldsmith. JJ Sciarra) pp 340-353. Philadelphia, Harper and Row, 1984. Sumnulu 1. lldeniz M. Ozel N: The incidence of pregnancy induced hypertension in southeast Turkey. Int J Gynecol Obstet 28: 21 I. 1989. Tahzib F: Epidemiological determinants of vesicovaginal fistulas. Br J Obstet Gynecol YO; 387. 1983. Tahzib F: Vesicovaginal fistula in Nigerian children. Lancet ii: 1291. 1985. Tuomivaara pregnancy treatment in United States
L. Kauppila A. Puolakka J: Ectopic an analysis of the etiology, diagnosis and 552 cases. Arch Gynecol 237; 135, 1986. National Center for Health Statistics: Ad-
vance report of final mortality statistics. 1985. NCHC Monthly Vital Statistics Report 36(Suppl 5): I. 1987. Van der Merwe JV. Ombelet WUAM: Rupture of the uterus: a changing picture. Arch Gynecol 240: 159. 1987. Wadhawan S. Wacha DSO: A review of urinary listulae in a university teaching hospital. Int J Gynecol Obstet 21: 381. 1983. Walton SM: Uterine rupture in Kenya: a guide to prevention and early diagnosis. East Afr Med J 55: 9, 1978. Wasserheit JN: The significance and scope of reproductive tract infections among Third World women. Int J Gynecol Obstet (Suppl3): I, 1989. Westrom L. Bengtsson LP, Mardh PA: Incidence. trends. and risk of ectopic pregnancy in a population of women. Br Med J 282: 15. 1981. World Health Organization: Geographic variation in the incidence of hypertension in pregnancy. Am J Obstet Gynecol 158: 80, 1988.
Address for reprints: L.S. Liskin Center for Communication Programs Johns Hopkins University School of Hygiene and Public Health 527 St. Paul Place Baltimore, MD 21202, USA
Int J Gynecol Obstet, 1992, 31: II-81 International
Federation
of Gynecology
Maternal morbidity comments
and Obstetrics
in developing
countries:
a review and
L.S. Liskin Johns Hopkins University Center ,jiw Conununicution Programs. School of’Hygiene cd
Public Hedth. 527 3. Puul Pluce, Bdtimow.
MD 21202, USA) (Received (Revised
February
26th.
1990)
and accepted June 13th, 1991)
Abstract The incidence and prevalence of postpartum maternal morbidity in developing countries are poorly understood. Methodologic problems, such as lack of standard definitions, misclassification of illnesses, use of nonrepresentative samples, and inadequate validation for selfreported data, tend to compromise existing studies. Available data suggest that serious acute illnesses are common, affecting as many as 20% of mothers who deliver in hospitals in some areas. Providing good antenatal andfamily planning services should significantly reduce acute and chronic sequelae after parturition.
Keywords: Maternal morbidity; Obstetric complications; Developing countries. Introduction
For many years maternal and child health research focused on the child, rather than the mother. Recently, however, attention has turned to the maternal risks of pregnancy and childbearing. This attention has centered largely on mortality. Global estimates suggest that every year about 500 000 women die from the complications of pregnancy and childbirth. 0020-1292/92/$05.00 0 1992 International
Federation
Published and Printed in Ireland
of Gynecology
and Obstetrics
Unfortunately, mortality statistics only tell half the story. The incidence of maternal morbidity - both short- and longterm - is unknown. The most commonly quoted estimate - 16 episodes of illness for every maternal death - is based on a small study (published in 1980) of about 270 women in one Indian village [20]. That this document represents a major source of information on maternal morbidity is a clear indication of the need for more intensive research. In developing countries community surveys are the usual sources of information on morbidity, but these instruments rarely include questions on pregnancy. Most have focused on childhood conditions and infectious diseases among adults. Hospital studies have also been published, but because relatively few women in developing countries deliver their infants in hospitals, these results most likely are not representative of the population. Moreover, hospital studies shed light only on the acute complications of pregnancy. In contrast, longterm consequences of pregnancy are not considered by hospital studies and, indeed are missing from almost all research. Accurately defining maternal morbidity is one of the major problems of research directed toward pregnancy-related illness. Misclassifications are common. Many condi-
78
L&kin
tions that are obstetric in origin, such as ectopic pregnancy or vaginal fistulas, are categorized as gynecologic problems. Illnesses are variously and inconsistently categorized as conditions, complications, or complaints. Definitions and terminology for specific illnesses may vary. For example, some authors describe all hypertension in pregnancy as toxemia; others differentiate between preeclampsia and eclampsia. Specific diagnostic criteria are only rarely provided. Vague terminology for some illnesses, for example, problems with lochia, is common. International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD) classifications are used in some but not all studies. Perceptions of what constitutes morbidity vary. Research to date has focused on complications that are measurable and potentially life-threatening, such as hypertension or vaginal bleeding. The so-called minor complaints of pregnancy - nausea and vomiting, backache, fatigue and sleeplessness - are only rarely addressed even though these conditions may significantly impair women’s wellbeing and their ability to work. Conversely, women may not view some complications as illness. Swelling of the hands and face is an ominous sign to health workers, but few women will regard this as illness. The majority of women in the world go through pregnancy and childbirth without any assistance from formally trained health care providers. Under these circumstances, most illnesses, like most deaths, fail to attract the attention of health care providers. If, however, the often quoted estimate of maternal morbidity - 16 illnesses for every death - is correct, then roughly 8 million women experience nonfatal pregnancy-related complications every year. Such a large burden of illness - much of it preventable - calls for immediate attention.
world. Published reports may contain ascertainment bias in that they represent select populations of women who received antenatal care. For example, one retrospective community survey in two Chinese communities estimated the prevalence of pregnancy-related illness in 917 women [42]. About 37% of the women experienced some illness during pregnancy; 21% had difficulties during labor; and 6% had postpartum complications. The most common antenatal conditions were preeclampsia and anemia. Almost one in every five women was anemic. Some 10% needed cesarean sections. Hemorrhage was the most frequent complication in the puerperium. It is highly unlikely that this study is representative of women’s experience in other developing countries. Probably all the women in these two communes received antenatal care, and apparently all gave birth in health facilities. Whereas over 70% of the women were primigravidas, most were in their early 20s the safest age to give birth. Thus, reported complication rates and serious complication rates may be low. In other countries, particularly where women give birth at very young ages, where multiparity and grand multiparity are the norm, and where antenatal care is limited, morbidity is, in all likelihood, more common. It is unfortunate that hospital studies are the major sources of information from many locations. For example, one of the largest hospitals studies, in Zaria, Nigeria, reports a high frequency of complications, particularly among unbooked women - those who received no antenatal care. With the exception of preeclampsia, various complications were two to five times more common among unbooked women than women who received antenatal care (see Table 1). Findings such as these are the rule, rather than the exception.
Prevalence of pregnancy-related
Incidence and prevalence of specific illnesses
illness
The prevalence of pregnancy-related illness has received little attention in the developing
Pregnancy-related illness can be grouped into several categories: (1) short-term, acute
Muternul
Table I.
Selected obstetric complications
Complications
Disproportion prolonged
and
in Ahmadu
Bello University
Hospital,
Zaria.
morbidity
Nigeria,
in dadoping
1976-1979,
Booked women
Unbooked
with complications
with complications
by booking
No.
‘%I
No.
‘%I
status.
827
5.6
2.054
26.9 6.4
labor
Preeclampsia
888
6.0
490
135
0.9
389
5.1
228
1.5
547
7.2 2.3
Antepartum
hemorrhage
rupture
Postpartum Retained
79
women
Eclampsia Uterine
countries
hemorrhage
placenta
Cesarean section .%urce: Harrison
26
0.2
177
255
1.7
390
5.1
26
0.2
889
I I.6
941
6.4
1,097
14.3
1985 [30].
complications directly related to pregnancy and the puerperium such as hemorrhage, obstructed labor, and infection; (2) chronic complications such as vaginal fistulas, that may occur at the time of labor and delivery or uterine prolapse that may occur many years later; and (3) associated illnesses - malaria and non-A, non-B hepatitis - that either occur or progress rapidly because of reduced immunity in pregnancy. While scant information on incidence is available for most of these conditions, data on longterm complications are particularly sparse. Short-term complications Pregnancy-induced hypertension. Assessing
the incidence of preeclampsia is particularly difficult because definitions of the disorder and case identification vary widely. A recent WHO collaborative study used a standardized diagnostic protocol to evaluate the incidence and eclampsia among of preeclampsia primigravidas in four Asian countries [78]. Clinical diagnosis of hypertensive disorders of pregnancy ranged from 1% in Vietnam and Thailand to 5% in Burma and 31% in China. Although the incidence of eclampsia was much lower than that of preeclampsia, particularly in China, differences between the four populations were statistically significant. The
lowest rate, 0.1X, was found in China and the highest, 0.9% in Thailand. In China, many more women with preeclampsia received medical treatment than in other countries. This may explain why the rate of eclampsia is lowest (Golding, personal communication). Hospital studies reporting the prevalence of preeclampsia also vary widely. Rates of eclampsia, on the other hand, show less variation - one to two cases per 1000 deliveries in Tanzania [5], India [lo], and Kenya [9], and 4-5 per 1000 in Jamaica [32] and Ilorin, Nigeria [l]. Considerably higher rates have been reported - 23 cases per 1000 pregnancies in Zaria, Nigeria [30] and 19 per 1000 deliveries in southeast Turkey [68]. Like many other complications, eclampsia occurs most often among the youngest mothers. In a Tanzanian study of 2800 primigravidas, almost three-quarters of the 36 cases of eclampsia occurred among women under 20 [4]. Similarly, among Nigerian primigravidas, girls younger than 15 were six times as likely to develop eclampsia as women aged 20-24 [30]. Ectopic pregnancy. An ectopic pregnancy is one of the most dangerous complications of pregnancy. Mortality is high because of heavy internal bleeding, frequent misdiagnosis and delay of appropriate treatment. In the United
80
Liskin
Table 2.
Rates of ectopic pregnancy,
Region and
Date
country
hospital studies 1963-1984.
No. of
Per 1000
ectopic
deliveries
Reference
pregnancies
Africa Kenya
1967-1968
119
7.6
I461
Mozambique
1987-1988
103
8.3
I151
Nigeria
1978-1979
100
23.2
Nigeria
1977-1987
I98
4.8’
1441
South Africa
1983-1984
100
15.2”
[431
Tanzania
1971-1977
251
10.3
151
Asia India
1964-1973
500
4.4
[361
Singapore
1975-1980
I21
161
Singapore
I972-
I48
3.7 2.9
75
6.2
I311
I977
[581
[lgl
Middle East Jordan
1976-1982
1Rate per 1000 live births.
States, in 1985, ectopic pregnancy accounted for less than 2% of all pregnancies but caused 11% of all maternal deaths [72]. The incidence of ectopic pregnancy in the United States and Europe has increased markedly since the 1970s [ 12,40,45,49,67, 71,771. In the United States, reported cases increased from 17 800 in 1970 to 78 400 in 1985. The rate per 1000 pregnancies rose threefold, from 4.5 to 15.2 [7,23,40]. Much less information is available in developing countries (see Table 2). Hospital studies in African countries document a range of rates from 4.78 to 23.2 ectopic pregnancies for every 1000 deliveries. In one Nigerian hospital ectopic pregnancy accounted for 6% of all gynecological admissions and 15% of all emergency admissions [58]. Postpartum infection. Postpartum and postabortion infection are common in developing countries. In Nigeria and India from 2 to 5% of newly delivered women develop genital or urinary tract infection [30,36]. In a Kenya study, by the 7th day postpartum, 20% of women had upper genital
tract infections [63]. In contrast, only 1% of the women in two Chinese communes where antenatal care was common developed infection after delivery [42]. Complications during labor - obstruction, prolonged labor, premature rupture of membranes, as well as any kind of surgical delivery or use of instruments - increase the risk of infection after the delivery. Sexually transmitted diseases (STDs), particularly gonorrhea and chlamydial infection, also are important risk factors. In the Kenyan study cited above, women with gonococcal infections had a fourfold risk of developing upper genital tract infection, and women with chlamydial infection faced a two-fold risk [63]. The prevalence of gonococcal and chlamydial infections was 7% and 23% respectively [63]. Other studies confirm the high rate of STDs in pregnant woman in Africa. In various countries from 3 to 22% of pregnant and postpartum women have gonococcal infections and from 5 to 9% chlamydial infections [41]. Rates are lower in Asia and in America [761.
Murernul
Table 3.
Prevalence
Region and country
of obstructed
labor,
hospital
nmrhidity
in developing
coun!ries
8I
studies.
Date
No. of cases of obstructed labor
1%)of deliveries
Reference
1976-1979 1984-1986 1981-1982
1239” 740 319
5.5 19.9 17.8
1301 1251 [341
1976-1980 1979-1980 1977
1494 1494 I28
10.2 11.5 2.9
[l II 1131
1101
224
II.3
1321
Africa Nigeria Zaire Zaire Asia Bangladesh Bangladesh India Caribbean l966- I969
Jamaica “Prolonged
labor
Obstructed labor. A large proportion of hospital deliveries, particularly in Africa, are complicated by obstructed labor (see Table 3). Several risk factors for obstructed labor have been documented - young age, primiparity, and short stature. In Zaria, Nigeria, women younger than I5 are three times as likely to experience disproportion and more than two times as likely to labor more than 24 h than women age 20-24 [30]. In Sierra Leone, 13% of women shorter than 5 ft required cesarean section for disproportion compared with only 4% of taller women [2]. Several conditions prevalent in developing countries - poor nutrition, young age at marriage, and early childbearing - together lead to difficult labor and increased risks of postpartum infection and longterm complications. Uterine rupture. Rupture of the uterus is a fairly frequent and often fatal complication of labor and delivery in developing countries. Reports from African hospitals show rates as high as 11 cases of uterine rupture per 1000 deliveries (see Table 4). Mortality is high and ranges from 9 to 42%. Declining incidences of fatality rates of uterine rupture have been
reported in Cameroon [53], Guinea [8] and South Africa [39]. Improvements in obstetric care, particularly better monitoring of labor with partograms, and increased availability of maternity services account for this decline [39,53]. Uterine rupture often involves other injuries to pelvic organs, particularly the bladder. In one survey of 129 cases of uterine rupture, 15% of women experienced rupture of the bladder [39]. Vesicovaginal fistula also occurs but less frequently. After hysterectomy or surgical repair of the uterus, infection and other complications are common. In one Iranian study, the average hospital stay for surviving patients was 15.5 days [61]. Most uterine ruptures are caused by cephalopelvic disproportion and/or obstructed labor. However, spontaneous ruptures occurred in 20-75% of cases in the studies cited in Table 4. Rupture of a cesarean section scar is reported in 20-25% of cases in most studies. A surprisingly large percentage of ruptures (from 3 to 22%) is caused by interventions of health workers or traditional birth attendants. Use of forceps, internal verRevielc
Liskin
82
Table 4.
Prevalence of uterine rupture
Region and
Date
country
and case-fatality
rates, selected hospitals studies. 1952-1983.
No. of
Rate per
‘%I
cases
1000
died
Reference
deliveries
Africa
l967-1974a
126
2.6
Nigeria
1965-1972
I44
8.9
Nigeria
1975-1986
227
6.
South Africa
1980-1983
129
South Africa
Mid-1970s
I.1 2.7
South Africa
1968-1982
89
I.1
Tanzania
1971-1977
83
3.4
Uganda
I952-
I71
10.7
Zambia
1958-1978
I05
6.7
9 27 0 I9 20 42 l4h 20 8 8 3 12 6 I2 37 28
Cameroon
1973-1976
70
1.9
Guinea
1986-1988
122
I.8
Kenya
1975
I8
4.2
Malawi
1977
I05
2.5
Nigeria
1978-1983
65
10.8
Nigeria
1974-1980
106
6.67
Nigeria
1976-1979”
203
9.0
I958
I
1531
I81 1751 1161 I221 1481 1301 I541 1281 1371 1391 1731 151 [651 1331
Asia ml Pacific India
1964-1973
106
0.9c
22
1361
India
1953-1959
I64
2.1
II
1381
Papua New Guinea
I964-
45
7.5e
29
1171
I973
Middle East aod North Africa Libya
1977-1980
96
I.7
5
HI
Iran
1967-1977
64
1.4
9
1611
Israel
1960-1975
12
0.5
0
1261
Jordan
1957-1965
I04
4.2
37
I31
“Both series from Ahmadu ‘All
Bello University,
deaths among unbooked
Zaria.
Nigeria.
women.
CRate per 1000 live births. ‘Rate
per 1000 confinements.
sion of the fetus, craniotomy, and particularly improper use of oxytocin are the procedures most often associated with uterine rupture. Several traditional birth practices also have been implicated. In Uganda and Nigeria, for example, herbal medicines used by traditional birth attendants are reported to have oxytocic properties [65]. Also, packing the vagina with herbs can cause severe swelling of the cervix and vaginal stenosis, thus prolonging labor and increasing the risk of rupture [22]. Other practices to speed delivery such as pushing or Inr J Gynecol Obstet 37
standing on the abdomen and turning babies in the breech position also may rupture the uterus [53]. It is not clear how common these practices are, however. Longterm complications Uterine prolapse. Women with prolapse ex-
perience a variety of symptoms ranging from mild to severe. In one Nigerian survey of 278 women with second- or third-degree prolapse, about one-third reported difficulties with urination - pain, stress incontinence, and fre-
Table 5.
Percentage of women with uterine prolapse, by parity. WHO
Country
studies of family formation
patterns and health.
1976-1981.
No. of
‘%fwith
‘% of
‘%I of women
sample
women
prolapse
women
para 7+
population
examined
para
with prolapse
Location
of
l-2
with
prolapse
Colombia
Pakistan
Old urban zone
1063
a
2
25
Newly settled zone
1147
19
5
38
809
25
Semi-urban Urban
Philippines
Syria
Source: Omran
area
area
II42
II
II
37
6
I4
Rural area
1484
6
2
IS
Urban
1434
9
4
I5
IO
5
I3
6
IO
area
Damascus
1214
Sweidi
III6
3
Aleppo
I394
8
and Standley
1981 [56]. Omran
7
et al. 1976 [57]
quency. Backache and a sensation of pelvic pressure were also common. Other symptoms included constipation and pain on defecation [59]. When prolapse occurs during pregnancy or labor, women face increased risks of spontaneous abortion, retention of urine, urinary tract infection and premature labor [19,55]. Information on uterine prolapse in developing countries is scarce. The WHO studies on Family Formation and Health in Colombia, Pakistan, the Philippines, and Syria indicate that the condition is fairly common, affecting from 3 to 25% of women under 45 (see Table 5). Prevalence increases with age and parity. In most countries women with 7 or more children were two to seven times as likely to have uterine prolapse as women with one or two children. There are scattered reports on prolapse from other countries: One Indian hospital admitted a pregnant woman with uterine prolapse for every 572 obstetric cases. Repair of prolapse accounted for 75% of the major gynecologic operations in this hospital [ 191. A much lower rate was reported in a Nigerian hospital - one case for every 4700 pregnancies
[55]. In Sao Paulo, Brazil, a gynecological screening program for outpatients attending the hospital clinic with nongynecologic complaints found a rate of 40.4 per 1000 cases of genital dystopia, that is rectocele, cystocele, perineal rupture, or uterine prolapse [62]. Where marriage and childbearing begin early, prolapse may affect many younger women. In a series of 278 cases in northern Nigeria, 29% of women were younger than 30 [59]. In the WHO studies on Family Formation Patterns and Health from 2 to 10% of women younger than 25 were diagnosed with prolapse. Vaginal fistulas. How frequently Iistulas occur is unknown. In hospital studies in several Nigerian cities less than 1% of all deliveries were complicated by fistula [22,28]. It is likely that the condition is much more prevalent, however. In Ethiopia an estimated 1000 cases occur every year, and a small hospital has been built exclusively for fistula repair [29]. In Sudan 122 cases were treated at Khartoum Hospital in 20 months, comprising 16% of all major gynecological conditions [52]. Obstructed labor, particularly from ReriL,U
84
Liskin
cephalopelvic disproportion, causes most Iistulas. Young primiparous women are at greatest risk. In a study of 1443 Nigerian cases 52% of women were pregnant for the first time, and over one-third were 16 or younger. The traditional practice of cutting the vaginas of very young girls to facilitate sexual intercourse or childbirth - gishiri cuts - may cause listulas in young girls [70]. This practice, as well as uterine rupture or surgery, causes fistulas in older women. Fistulas are successfully closed by surgery in about 70-80% of first operations [24,35,74]. Stenosis of the vagina may occur, however, making intercourse painful or impossible. Women who became pregnant subsequently are at increased risk of urinary tract infections and, because they often must undergo cesarean section, are at greater risk of complications during delivery and in the puerperium [30,60]. One study reports a higher rate of spontaneous abortion after Iistula repair [47]. Fistulas reopened after childbirth in 15% of women, according to one small Nigerian study [24]. Access to and better use of health services will prevent almost all cases of fistulas. Data from Zaria, Nigeria, suggest that as the obstetric services of the major hospital in the area became better known and more women came for antenatal care and delivery, the incidence of fistulas declined. Between 1970 and 1978 the number of patients delivering in the hospital increased four-fold. The number of cases of fistula doubled, but the number coming from within 50 km of Zaria decreased steadily. By 1978 not one listula patient came from Zaria. The number of cases from areas farther away increased sharply [69]. Methodology
Measuring the extent of maternal morbidity is the first step to developing appropriate health interventions. It is not clear, however, which methodology is most appropriate for studying the short- or longterm risks of pregnancy. Three important issues, common
to all research on morbidity are: defining the morbidities to be studied, determining the appropriate population and validating selfreported information. Recent articles [14,66] have described the difficulties of studying maternal mortality. Studying morbidity involves many of the same problems and more. A maternal death is dramatic and unambiguous. Morbidity often is neither, although some illnesses - eclamptic fits for example - are obvious and unmistakable. As noted above, case identification and diagnosis of some maternal illnesses vary widely. Accurately estimating edema or amount of blood loss after delivery is difficult. Also, some conditions such as uterine prolapse are obvious on physical examination but in fact may cause relatively few symptoms and so will be underreported by women. Finally, some conditions have multiple causes and cannot be directly attributed to pregnancy. Secondary infertility, for example, is caused by sexually transmitted diseases as well as by postpartum infection. Obtaining a representative sample of the population and an accurate estimate of the incidence of morbidity in a community is not possible with in-hospital studies because many women deliver at home. Community- or population-based surveys of women are more representative, however, but not without problems. By definition, surveys exclude women who have died from pregnancy-related complications and thus may underestimate many conditions, and particularly those like eclampsia that often are fatal. To give the broadest possible picture of maternal morbidity in developing countries community surveys should involve multiple countries, geographic regions, and racial, religious and ethnic groups. This may shed some light on several unanswered questions about risk factors. A third major problem with morbidity surveys -prospective or retrospective - is validating self-reported information. Crosssectional studies result in underreporting and overreporting of illness. Retrospective survey
Muternul
data on pregnancy-related illnesses may be subject to recall bias. Women who have given birth to healthy children may be less likely to remember complications during pregnancy than women whose children died. Whether the woman wanted her child and how she feels about him/her also may bias her memory of pregnancy. The time between the pregnancy and the survey also affects recall. A study in rural Senegal on causes of death among children found that parents gave the most complete information on duration of illness and specific symptoms between 3 and 9 months after death [27]. It is not clear whether this finding can be applied to surveys of women themselves, however. Probably the best way to overcome these difficulties is to combine different sources of information. Studies of maternal mortality using a variety of sources - hospital records and interviews with health workers, TBAs and family members - have produced more information on maternal deaths than any one source alone. Similarly, morbidity surveys plus hospital records give a better estimate of the numbers of women who experience any complication, the types of complication and the major risk factors for serious morbidity and death. Neither community surveys nor hospital studies give a complete picture of the true burden of maternal morbidity or mortality to women, to their families and to their communities. How can this be measured? Researchers from WHO and the Kaiser Foundation have developed a method for assessing the health impact of different diseases in developing countries. This method uses information on incidence rates, case-fatality rates, the extent and duration of disability from various diseases, and life expectancy to measure the number of healthy days of life through illness, disability and death [50]. When the method was used in Ghana, complications of pregnancy ranked sixteenth among other conditions in the number of days of healthy life lost. This method is child-oriented, however, because it ranks individuals in direct proportion to their
morbidity
in dewloping
countric~s
85
life expectancy at age of onset of illness. Thus the death of a child is regarded as costing the community more than the death of an adult. This approach also ignores the impact of death or disability of an adult, particularly a pregnant woman, on the life expectancy of her dependents. A different kind of methodology is needed to assess more accurately the true cost to society of maternal morbidity and mortality. Without accurate information effective prevention strategies cannot be developed. Nor is it likely that the needed resources will be allocated to fund these strategies and to shift the focus of research to a more even balance between mother and child. The research on maternal morbidity is just beginning. While the full picture is still incomplete, existing studies clearly show that pregnancy-related illnesses exact a heavy toll on women’s lives at the time of childbirth and for years afterwards. The loss to women, to their families and to their communities has yet to be calculated. More tragic still, is that much of this illness is preventable. Good antenatal care, emergency transport services, education, and above all, family planning services to prevent high risk births can markedly reduce the incidence and prevalence of maternal morbidity. Developing these services and minimizing short- and longterm maternal illnesses are critical challenges for health professionals in the 1990s. References Adetoro
00:
The pattern
of llorin Teaching
of eclampsia at the University
Hospital (UITH)
Ilorin.
Nigeria.
Int J
Gynecol Obstet 31: 221, 1990. Aitken
IW.
Walls B: Maternal
disproportion Akasheh
F: Rupture
of rupture. Arkutu
height and cephalopelvic
in Sierra Leone. Trop
Dot
16: 132. 1986.
of the uterus: analysis of 104 cases
Am J Obstet Gynecol
101: 406.
1968.
AA: A Clinical study of maternal age and parturi-
tion in 2791 Tanzanian
primiparae.
Int J Gynecol
Obstet
16: 20. 1978. Armon
PJ: Maternal
Tanzania.
Trans
Atputharajah aetiological Gynecol
deaths in the Kilimanjaro
R Sot Trop V.
factors
Tubal
pregnancy:
in
cases. Singapore
13:. 78, 1982.
I I7
region of
Med Hyg 73: 284. 1979. a
review
of
J Obstet
86
Liskin
7
Atrash HK. Hughes JM, Hogue CJR: Ectopic pregnancy in the United States. 1970-1983. Morbid Mortal 35: 2955. 1986.
8
Balde MD, Bastert G: Decrease in uterine rupture in Conakry. Guinea by improvments in transfer management. Int J Gynecol Obstet 31: 21. 1990. Bansal YP: Pre-eclampsia/eclampsia: a profile from Pum-
9
IO
II
12 13
14 I5
I6 I7 I8 I9 20
21 22 23
24
wani Maternity Hospital. Nairobi, Kenya. East Afr Med J 62: 691. 1985. Basu S: Maternity care in India - an analysis of obstetric deliveries in selected hospitals. In: India Fertility Research Programme (IFRP). 5th contributors conference. 16 p. Calcutta, IFRP. 1977. Begum SF, Nahar K. Jahan FA. Khan AR: A comparative study of the pattern of maternity care services in different hospitals and clinics in Bangladesh. Presented at the 8th Asian and Oceanic Congress of Obstetrics and Gynaecology. October 25-31. 1981, 16 p. Beral V: An epidemioiological study of recent trends in ectopic pregnancy. Br J Obstet Gynaecol 82: 775. 1975. Bhuiyan AB. Ahmed G, Rahman S: Maternity cases at Rangput Medical College Hospital. In: Bangladesh Fertility Research Programme (BFRP). 5th ontributors
27
deaths using a standarized questionnaire: a Senegal. Liege, Belgium and Siena. Italy. Union for the Scientific Study of Population of Statistics, University of Siena, 1986. 41 28 29
30
31 32
33
onference. Dacca. Bangladesh. December 13. 1980. Dacca. Bangladesh, BFRP. 1981. pp 57-68. Boerma JT: Levels of maternal mortality in developing countries, Stud Fam Plann 18: 213. 1987.
34
Bugalho A. Strolego F. Pregazzi R, Osman N, Ching C: Extrauterine pregnancy in Mozambique. Int J Gynecol Obstet 34: 239. 1991. Bullough CHW: Analysis of maternal deaths in the cen-
35
tral region of Malawi. East Afr Med J 58: 25, 1981. Campbell GR: Maternal mortality at Garoka Base Hospital. Papua New Guinea Med J 17: 335. 1974. Chew SY: A 6 year review of ectopic pregnancy. Singapore Med J 20: 395. 1979. Das RK: Genital prolapse in pregnancy and labor. Int Surg 56: 260. 1971. Datta KK. Sharma RS. Razack PMA. Ghosh TK. Arora RR: Morbidity pattern amongst rural pregnant women in - a cohort study. Health Popul Alwar. Rajasthan Perspect Issues 3: 282. 1980. Eden RD. Parker RT, Gall SA: Rupture of the pregnant uterus: a 53-year review. Obstet Gynecol 68: 671. 1986. Elkins T. Onwuka E, Stovall T. Hagood M. Osborn D: Uterine rupture in Nigeria. J Reprod Med 30: 195. 1985. Ellenbrock T. Atrash HK, Hogue CJR. Hughes JM: Ectopic pregnancy mortality in the United States, 1979-1982. Morbid Mortal 36: 13. 1987. Evoh NJ. Akinla 0: Reproductive performance alter the repair of obstetric vescio-vaginal fistulae. Ann Clin Res
36
37
38 39 40
41
42
IO: 303. 1978. 25
26
I: The grand mutlipara - is it a problem? A review of 5785 cases. Int J Gynecol Obstet 23: 321. 1985. Garenne M. Fontaine 0: Assessing probable causes of
Family Health International monitoring: Karawa health Triangle Park, North Carolina,
(FHI): Pregnancy care zone. Zaire. Research FHI. 1988. I51 pp.
43
Fuchs K. Peretz BA. Marcovici
R, Paldi E, Timor-tritsh.
44
study in rural International and Institute p.
Groen GP: Uterine rupture in rural Nigeria: review of 144 cases. Obstet Gynecol 44: 682. 1974. Hamlin RHJ. Nicholson EC: Experiences in the treatment of 600 vaginal fistulas and in the management of 80 labours which have followed the repair of these injuries. Ethiopian Med J 4: 189, 1965. Harrison KA: Child-bearing, health and social priorities: a survey of 22.774 consecutive hospital births in Zaria. northern Nigeria. Br J Obstet Gynaecol YZ(supp/ 5): I. 1985. Hasan AA: Ectopic pregnancy: a seven-year survey. Eur J Obstet Gynecol Reprod Biol 16: 237, 1983. Hay DM, Boyd JJ: A study of the obstetric performance of the adolescent Jamaican primigravida. Am J Obstet Gynecol 116: 34. 1973. Heij HA. Te Velde ER. Cairns JM: The treatment of rupture of the pregnant uterus, analysis of 93 cases treated in a rural hospital in Zambia. Int J Gynecol Obstet 22: 415. 1984. Janowitz B. Lewis J, Burton N. Lamptey P. eds: Reproductive Health in Africa: Issues and Options. Research Triangle Park. North Carolina. Family Health Institute. 1984. 69 p. Kelly J: Vesicovaginal tistulae. Br J Urol 5I: 208. Konar M. Sikdar K, Basak S. Lahiri D: Maternal mortality: ten years’ survey in Eden Hospital. J Indian Med Assoc 75: 45. 1980. Konje JC. Odukoya OA. Lddipo OA: Ruptured uterus in lbadan - A twelve year review. Int J Gynecol Obstet 32: 207. 1990. Krishna Menon MK: Rupture of the uterus: a review of I64 cases. J Obstet Gynaecol Br Emp 6Y: 18. 1962. Ldchman E. Moodley J. Pitsoe SB. Philpott RH: Rupture of the gravid uterus. South Afr Med J 67: 333. 1985. Lawson HW. Atrdsh HK. Saftlas AF. Franks AL. Finch EL, Hughes JM: Ectopic pregnancy surveillance, United States, 1970-1985. Morbid Mortal Weekly Rep 37: 9. 1988. Lettenmaier C. Liskin L, Church C. Harris J: Mothers’ Lives Matter: Maternal Health in the Community. Population Reports. Series L. No. 7. Baltimore, Johns Hopkins University, Population Information Program. 1988, 40 p. Li BY, Dong A-M. Zhuo JR: Outcomes of pregnancy in Hong-qiao and Qi-yi communes. Am J Pub1 Health 72(Suppl 9): 30. 1982. Lindow SW, Moore PJ: Ectopic pregnancy: analysis of I00 cases. Int J Gynecol Obstet 27: 371, 1988. Makinde 00. Ogunniyi SO: Ectopic pregnancy in a defin-
45
46 41
48 49
50
51 52 53 54 55
56
51
58 59
60
61 62
ed Nigerian population. Int J Gynecol Obstet 33: 239, 1990. Makinen Jl. Erkkola RU, Laippala PJ: Causes of the increase in the incidence of ectopic pregnancy: a study on 1017 patients from 1966 to 1985 in Turku. Finland. Am J Obstet Gynecol 160: 642, 1989. Maley A. Auma S: Ectopic pregnancy in Nairobi. Kenya. Scot Med J 15: 172. 1970. Mati JKG: Vescicovaginal listula. In: Reproductive Health in Africa (eds JKG Mati, OA Ladipo). pp I81 - 191. Baltimore, Johns Hopkins Program for International Education in Gynecology and Obstetrics. 1984. Megafu U: Factors influencing maternal survival in ruptured uterus. Int J Gynecol Obstet 23: 441. 1985. Meirik 0: Ectopic pregnancy during 1961-78 in Uppsala County. Sweden: impact of demographic factors on overall incidence. Acta Obstet Stand 60: 545. I98 I. Morrow RH. Smith PG. Nimo KP: A quantitative method of assessing the health impact of different diseases in less developed countries, July 1980, I8 pp (unpublished). Murphy M: Social consequences of vesico-vaginal listula in northern Nigeria. J Biosoc Sci 13: 139, 1981. Mustafa AZ, Rushwan HME: fistulae in the Sudan. J Obstet Nasah BT, Drouin P: Review uterus in Cemeroun. Trop Dot
Acquired genito-urinary Gynaecol 78: 1039. 1971. of 70 cases of ruptured 8: 127. 1978.
Obayemi TOB: Maternal mortality in rupture of the iterus. Nigerian Med J 8: 433. 1978. Ogunbode 0, Aimakhu VE: Uterine prolapse during pregnancy in Ibadan. Am J Obstet Gynecol 116: 622. 1973. Omran AR, Standley CC eds: Family formation patterns and health - further studies: an international collaborative study in Colombia, Egypt, Pakistan, and the Syrian Arab Republic. Geneva, World Health Organization, 1981. 464 pp. Omran AR, Standley CC, Azar JE. Bertan M. Guzman V. Nahapetian V, Pisharoti KA: Family Formation Patterns and Health. Geneva, World Health Organization. 1976. 562 pp. Oronsaye AU. Odiase Gl: Incidence of ectopic pregnancy in Benin City, Nigeria. Trop Dot II: 160. 1981. Otubu JA, Ezem BU: Genital prolapse in the Hausa/Fulani of northern Nigeria. East Afr Med J SY: 605. 1982. Otubu JA. Kumi GO, Ezem BU: Pregnancy and delivery after successful repair of vesicovaginal listula. Int J Gynecol Obstet 20: 163, 1982. Paydar JA. Hassanzadeh A: Rupture of the uterus. Int J Gynecol Obstet IS: 405, 1978. Pinotti JA, Brenelli HB. Moragues JD. Pastene LL. Ramos RSB, Barini R. Da Silva Alves C. Stano MT, Bigatti LE: Preventive obstetrics and gynecology program: pilot plan for integrated medical acre. Bull Pan American
Health
Organization
1.5: 104. 1981.
63
64
65 66 67
68
69 70 71
72
73 74
75 76
77
78
Plummer FA, Laga M, Brunham RC. Piot P, Ronald AR. Bhullar V, Mati JY. Ndinya-Achila JO, Cheang M. Nsanze H: Postpartum upper genital tract infections in Nairobi, Kenya: epidemiology, etiology, and risk factors. J Infect Dis 156: 92. 1987. Rahman J. Sibai MH Al-, Rahman MS: Rupture of the uterus in labor: a review of 96 cases. Acta Obstet Gynecol Stand 64; 31 I. 1985. Rendle-Short CW: Rupture of the gravid uterus in Uganda. Am J Obstet Gynecol 79:. I 114. 1960. Royston E, Lopez AD: On the assessment of maternal morbidity. World Health Statist Q 40: 214. 1987. Sivin I: IUD-associated ectopic pregnancies. 1974 to 1984. In PRFR Series on Fertility Regulation (eds GI Zatuchni, A Goldsmith. JJ Sciarra) pp 340-353. Philadelphia, Harper and Row, 1984. Sumnulu 1. lldeniz M. Ozel N: The incidence of pregnancy induced hypertension in southeast Turkey. Int J Gynecol Obstet 28: 21 I. 1989. Tahzib F: Epidemiological determinants of vesicovaginal fistulas. Br J Obstet Gynecol YO; 387. 1983. Tahzib F: Vesicovaginal fistula in Nigerian children. Lancet ii: 1291. 1985. Tuomivaara pregnancy treatment in United States
L. Kauppila A. Puolakka J: Ectopic an analysis of the etiology, diagnosis and 552 cases. Arch Gynecol 237; 135, 1986. National Center for Health Statistics: Ad-
vance report of final mortality statistics. 1985. NCHC Monthly Vital Statistics Report 36(Suppl 5): I. 1987. Van der Merwe JV. Ombelet WUAM: Rupture of the uterus: a changing picture. Arch Gynecol 240: 159. 1987. Wadhawan S. Wacha DSO: A review of urinary listulae in a university teaching hospital. Int J Gynecol Obstet 21: 381. 1983. Walton SM: Uterine rupture in Kenya: a guide to prevention and early diagnosis. East Afr Med J 55: 9, 1978. Wasserheit JN: The significance and scope of reproductive tract infections among Third World women. Int J Gynecol Obstet (Suppl3): I, 1989. Westrom L. Bengtsson LP, Mardh PA: Incidence. trends. and risk of ectopic pregnancy in a population of women. Br Med J 282: 15. 1981. World Health Organization: Geographic variation in the incidence of hypertension in pregnancy. Am J Obstet Gynecol 158: 80, 1988.
Address for reprints: L.S. Liskin Center for Communication Programs Johns Hopkins University School of Hygiene and Public Health 527 St. Paul Place Baltimore, MD 21202, USA
