Is the second birth after death

It is important to survive the second day after the birth

Every year 529,000 women die as a result of pregnancy, childbirth or childbirth. The risk for the mothers of this world is not evenly distributed. It is highest in sub-Saharan Africa. Here 1 in 100 women dies in childbirth. That is twice as many as in South Asia and 50 times more than in industrialized countries. Sweden is considered the safest haven for pregnant women. The risk of dying in childbirth at some point in life is 1 in 30,000 women. These enormous differences between the chances of survival of mothers worldwide have long been known as the greatest disparity in medical statistics. However, it is still not fixed. The eight development goals of the United Nations also make it clear how neglected the world is to childbirth. Millennium Goal 5, which aims to reduce maternal mortality by 75 percent, has made the least progress to date. On the occasion of these sobering results, health experts have published a series of articles in the British journal “The Lancet” (vol. 368) on the subject of maternal mortality.

Unnecessary investigations

There are many reasons why aid programs such as the Millennium Development Goals or the international initiative “Risk-Free Motherhood”, which is soon to be twenty years old, are stagnating. Ann Starrs of Family Care International in New York blames wrong strategies. Money has been wasted by screening countless healthy pregnant women in developing countries to identify risk cases. In reality, however, complications often arise without notice. In addition, the traditional obstetricians who are present at home births without medical expertise have been supported so far. Starrs emphasizes that these people did not have the equipment or training to deal with life-threatening complications.

The rivalry between various aid organizations also damaged the goal. In the 1980s, aid projects focused on children and newborns, while mothers were only considered in family planning. Then the focus shifted to maternal health, so that in 1997 a ten-point maternal health plan completely excluded children. What was ignored was the fact that newborn mortality is many times higher when the mother is deceased. But older children also have up to ten times the chances of survival if the mother is by their side. Because mothers remain life-giving.

Bungling withheld

Bleeding to death is the number one cause of death for mothers. 166,000 women per year suffer fatal blood loss at birth. After the bleeding begins, the mother has just six hours to get help. In many regions of the Third World this is impossible. Another common cause are infections, such as classic childbed fever, blood poisoning caused by poor hygiene. But pregnancy-related high blood pressure diseases such as preeclampsia also claim their victims. In industrialized countries, women are comparatively more likely to die of thrombosis. How often women die from abortions can only be estimated, says Carine Ronsmans from the London School of Hygiene and Tropical Health. She suspects that a large number of these cases are kept secret for legal or social reasons. Ronsmans refers to studies from Benin, Senegal, and Côte d'Ivoire that show that all deaths in early pregnancy were caused by abortion botch-ups. Indirect causes of death are also difficult to measure, as statistical data and diagnostic methods are lacking in many countries. Many women die from diseases such as malaria, tuberculosis, and anemia. However, these figures are not included in maternal mortality. HIV-infected women are four to five times more likely to die in childbirth than healthy people, according to studies from Uganda and Congo. In addition, the hormone situation in pregnant women complicates the course of AIDS. In addition, violent deaths do not appear in the statistics. So far, little attention has been paid to the connection between the murder or suicide of women and pregnancy. "But it is no coincidence," says Ronsmans, that domestic violence is the second leading cause of death during pregnancy in India. " And a study in Bangladesh showed that every fifth death of a single pregnant woman was a suicide.

On the other hand, the time of death is clear: Women are most likely to die one or two days after giving birth. The risk is increased in the last trimester of pregnancy and a week afterwards. But already on the third day after the birth, the chances of survival are much better. In Bangladesh, for example, the risk of dying on the first day after birth is 100 times higher than two years later. Therefore, it is now clear that special emphasis must be placed on professional help during and shortly after the birth. However, only half of all women worldwide have their child accompanied by a specialist. Millions of women are alone, others are at least cut off from medical help in emergencies.

Three deadly hurdles

However, if an expectant mother does end up in a hospital, her care is by no means guaranteed. On the contrary, the majority of deaths occur in hospitals, of all places. This is shown particularly drastically in the example of South Africa, where 94 percent of all maternal deaths occur in hospitals. There are mutliple reasons for this. Many women in developing countries only reach a hospital in a moribund state and practically die on the threshold. This is due to three life-threatening hurdles for a woman giving birth: First of all, it takes too long for an emergency to be recognized as such at home. Then the way to the hospital is often too far. And finally, valuable time passes before the woman is treated. It becomes even more complicated when financial and cultural barriers prevent women from seeking help. In addition, the quality of the hospitals is sometimes extremely questionable. A study from Ghana showed that the conditions in the hospitals only meet the simplest clinical requirements in just 17 percent of births. Marge Koblinsky of Johns Hopkins University in Baltimore estimates that 700,000 additional midwives and doctors will be needed worldwide to enable more women to have a safe birth in the future. Three times as many as are currently working.

But there is hope. Because maternal mortality can be combated as efficiently as polio was at the time. In fact, the risk of dying in childbirth can be reduced by up to 99 percent. The mortality rate, i.e. the number of women who die during pregnancy, childbirth or the puerperium, calculated for every 100,000 live births, is currently 400 on average worldwide. In industrialized countries, the mortality rate has already been reduced to below 10. In the late 19th century, the rate halved due to professional obstetrics. Antibiotics, better surgical techniques, disinfectants, and more hospitals brought further advances. Often little is needed: in Romania, for example, a change in the law halved the death rate: a restrictive abortion law that made illegal methods popular was abolished in 1991. Among the developing and emerging countries, Thailand, Sri Lanka and Malaysia have reduced their death rates by 75 to 98 percent over the past 25 years. Egypt and Honduras halved their numbers in seven years, even though they were already below the global average.

Among other things, long-term investments in midwifery training and hospitals and free medical care for women giving birth are successful. In addition, conditions improve significantly even in the poorest, rural areas as soon as health services are set up, such as in Matlab, Bangladesh.

In the short term, even small changes such as mosquito nets against malaria or vitamin A help with malnutrition. Misoprostol, a substance that prevents excessive bleeding and is given instead of oxytocin, also gives rise to hope. Because in the hospital, women receive oxytocin via a drip, which supports the vital contraction of the uterus after childbirth. In poor countries, however, it is hardly possible to store and administer this substance correctly. Misoprostol, on the other hand, is cheaper and can be swallowed.

The priority should be the establishment of health centers for labor mothers in southern Africa and Asia, says Wendy Graham of the University of Aberdeen. In addition, one must enable emergency transfers to hospitals. A 24-hour birth service for 120,000 residents is available with ten midwives in one hospital and ten other midwives in the region. What is also important are stronger health systems in the weak regions. And health systems that understand that every woman has the right to survive the birth of a child.

"Every death is a tragedy"

The physician Katharina Quack Lötscher researches maternal mortality in Switzerland. Four to seven women die each year due to pregnancy

NZZ am Sonntag: A hundred years ago, a woman risked her life with every birth, so to speak - do we know how great this risk was in historical times?

Katharina Quack Lötscher: Scientists assume that without modern civilization and medicine, around every hundredth woman dies as a result of pregnancy.

What medical improvements have contributed most to reducing maternal mortality?

Ignaz Semmelweis' discovery that obstetricians can also transmit pathogens had a very large impact on maternal mortality. Hand washing was the first aseptic technique introduced around 1880. A second major improvement was brought about around 1940 by antibiotics and the possibility of blood transfusions. This enabled the two main causes of death during pregnancy and childbed - sepsis or blood poisoning and bleeding - to be combated.

And what has the curve been like over the past few decades?

The maternal mortality rate in western countries is still decreasing steadily, but the decrease is getting slower and slower.

The study for the years 1985-94 showed that in Switzerland 76 mothers died in connection with pregnancy and childbirth during this period, i.e. around 7 per year.

That's right. We are now in the process of doing the same analysis for the next 10 years, 1995-2004. During this period we have only 44 deaths as a starting point. However, this is only the information provided by the Federal Statistical Office. As we know from the first study, there may be additional cases, for example due to inquiries from the forensic medicine institutes.

So you will review each and every case carefully?

Yes, that is the aim of our study. In each case, we contact the institution that issued the death certificate and inquire about the exact circumstances. Of course, all cases are anonymized for this. It's all about learning something for the benefit of future pregnant women in order to further reduce maternal mortality.

How exactly do you define maternal mortality?

In the past, only direct deaths were included, i.e. when a woman died directly due to pregnancy or childbirth. Today, indirect cases are also included, i.e. the death of a mother that is not directly related to pregnancy. The different definitions make international comparison difficult, as do many borderline cases: pregnancy can limit therapy, for example in the case of cancer. Then the question arises whether the woman died because of the pregnancy or "only" because of the cancer. Or it is not recognized that the death is related to pregnancy, for example in the case of early miscarriages in the first few months.

The 1985-94 study shows that maternal mortality is usually underestimated, which means that there are always cases that do not appear in the statistics.

It is assumed that maternal mortality is underestimated everywhere in Europe, and depending on whether this so-called "underreporting" is included, the death rate is slightly higher or lower. The UK has a very solid reporting system, where every pregnancy-related death is examined in detail by a special commission. Unfortunately, we don't have that.

There are 7 deaths for every 100,000 births in Switzerland. How do we stand internationally with this?

We are in the middle of the Western European countries. In Eastern Europe the rate will rise to 30 to 35 deaths per 100,000 births.

What the Swiss statistics also show: The risk of maternal death increases with the age of the woman.

That is a factor that we really need to be aware of. Much becomes more difficult in pregnancy the older a woman is. On the other hand, we cannot assess the risk at all for the very young women in Switzerland because we only have very few pregnancies in this age group.

It was also found that 76 percent of maternal deaths were delivered by caesarean section.

In fact, this is a very high rate of Caesarean sections, more than twice as high as the normal rate, which is almost 30 percent in Switzerland today. However, this does not mean that a caesarean section endangers the mother more than a normal birth. In most cases, a caesarean section was carried out because the life of the mother and / or the child was in danger - for example in the case of pregnancy poisoning.

When it comes to the causes of maternal mortality, pulmonary embolism is our top priority today.

This is the case in all European countries, pulmonary embolism or thromboembolism is very unpredictable and occurs suddenly, its deeper causes are diverse. Prophylaxis is therefore taken very seriously. I think the lower maternal mortality rate over the last 10 years could also be due to improved thrombosis prophylaxis - but that will only show when the next data are analyzed.

Is there a connection between maternal and child mortality?

Not directly. But there are points of contact, especially when delivery has to take place early in pregnancy. Then, of course, the risk of dying is high for the child.

Does it make sense to conduct intensive research into a very low maternal mortality rate?

The evaluation of these deaths is an important quality control for obstetrics. Every maternal death is, of course, a tragedy. Despite very good health care, short transport routes and specialized doctors, there is still a residual risk with every pregnancy. Unfortunately, maternal mortality will not go down to zero. Interview: Kathrin Meier-Rust