The impact of maternal health improvement on perinatal survival: cost-effective alternatives.

Each year, an estimated half million women die from complications related to child birth either during pregnancy, delivery or within 42 days afterwards. When pregnant women have complications, their infants are at greater risk of becoming ill, permanently disabled or dying. For every maternal death, there are at least 20 infant deaths: stillbirths, neonatal or postneonatal deaths. Altogether, an estimated 7 million infants each year die perinatally (stillborn or deaths within the first week of life). Low cost, feasible, and effective intervention strategies include: a) improved family planning and abortion services; b) obstetric care at delivery; and, c) prenatal services. Two hypothetical populations of one million (a low mortality and a high mortality country) are used to illustrate maternal and perinatal program strategies and priorities. In countries with high fertility, major reductions in maternal and infant deaths result both from reductions in the number of pregnancies through family planning and from improved obstetric care. Where fertility is already low, reductions result almost entirely from improved obstetric and prenatal care. The investments required are relatively low, while the potential gains are great. The cost to avert each death in a high mortality population is estimated between $800 and $1,500 or as low as $0.50 per capita per year. The priorities for programs targeting maternal and perinatal health depend on demographic, ecologic and economic factors, and should include the promotion of good health, not merely the avoidance of death. More operational research is required on various aspects of maternal and perinatal health; in particular, on the cost-effectiveness of different service components.

Sterilization in Bangladesh: mortality, morbidity, and risk factors.

Although surgical sterilization in Bangladesh is common and has been designated as the primary means of helping the country slow its population growth, no reliable information exists regarding the procedure's safety. To define the types and rates of medical complications associated with sterilization, we followed 5042 women and 264 men undergoing sterilization. The problems that increased most markedly after the procedure compared with before included painful urination, shaking chills, fever for at least 2 days, and frequent urination. Most of the postoperative problems could be predicted by the presence of the same problem before the operation. Factor analysis of complaints in those persons who did not have a specific preoperative complaint showed that complaints clustered into three groups: urinary tract symptoms (urinary urgency and frequency), skin problems (bleeding from the incision, sore with pus, and stitches or skin breaking open), and general complaints (weakness and dizziness). The patient's sex, the sponsor and patient load of the sterilization center, and the dose of sedatives administered to women were significantly associated with specific postoperative complaints. Five women died during the study, resulting in a death-to-case rate of 9.9/10,000 procedures tubectomies; four deaths were due to respiratory arrest caused by oversedation.

PIP: Data were collected from February-June 1980 on 5042 women and 264 men undergoing surgical sterilization in Bangladesh to define the types and rates of medical complications associated with sterilization. The major findings of this study are that: 1) one of every 1000 women undergoing sterilization in Bangladesh dies as a result of the procedure; 2) overuse of systemic sedatives is common and was the principle contributor to 5 deaths that occurred; and 3) chief health complaints are urinary tract symptoms, skin problems, and systemic complaints. The death-to-case rate of 9.9/10,000 procedures in this study is similar to the 10.0 deaths/10,000 cases estimated on the basis of a 1979 follow-up study in an Indian female sterilization camp. The presence of a complaint before the operation was generally a good predictor of postoperative complaints. Centers performing fewer than 200 procedures were associated with more complaints.

Maternal and abortion related deaths in Bangladesh, 1978-1979.

The incidence and causes of pregnancy-related deaths are unknown for most of Asia; only local area studies have been done for Bangladesh. Between December 1978 and May 1979, we interviewed 118 health workers in 63 hospitals and 732 non-hospital facilities to identify case reports of maternal and abortion-related deaths in Bangladesh. Of 1933 pregnancy-related deaths identified, 498 (25.8%) were due to induced abortion. Abortion mortality rates varied significantly in the 18 administrative districts; the highest were in Dinajpur and Chittagong, the most northern and southern districts, and the lowest in Comilla and Noakhali. We used an earlier study of maternal mortality to estimate that about 21,600 pregnancy-related deaths occur each year in Bangladesh. We estimate that about 7.5% of all pregnancy-related deaths were identified in this survey. We infer from these data that safe and effective fertility control, including abortion performed by adequately trained health workers in both in- and out-patient facilities, might be the most appropriate first step in preventing pregnancy-related deaths in Bangladesh.

Complications from induced abortion in Bangladesh related to types of practitioner and methods, and impact on mortality.

Health-workers in 795 health centres in Bangladesh were interviewed about complications arising from induced abortion in rural Bangladesh. 1590 cases of complications from abortion were reported. Dais (traditional birth attendants) and traditional practitioners were the larger groups of operators (42.1% and 18.1%, respectively). Menstrual regulation or dilatation and curettage (the medically approved procedures) were used 9.1% of the time. Nearly half the complicated abortions were induced by inserting a foreign object, such as a stick or root (sometimes treated with an herb), into the uterus and leaving it until either abortion or complications ensued. 498 abortion-related deaths were reported. The proportion of complicated abortions resulting in death was lowest for medically approved procedures (4.9%) and highest for vigorous physical activity (100%) and abdominal pressure (66.7%), although the last two together accounted for only 2.3% of abortion procedures. Women who died after abortion were more likely than were women who survived to be further along in their pregnancies. An extrapolation from these results gives a figure of 780000 abortions in Bangladesh in 1978 and 7800 deaths that year from abortion complications. Many of these deaths might have been prevented if a means of safe, affordable termination of unwanted pregnancy had been available.

PIP: Induced abortion, although illegal, is common in Bangladesh. A number of health workers were interviewed in 1978-79 in 795 health centers to investigate the magnitude of the problem in rural areas. There were 1590 reported cases of complicated abortions, of which 498, i.e. 31.3% were fatal. 42.1% of abortions were performed by traditional birth attendants, and 18.1% by traditional practitioners; a very small number was performed by husbands, or by the women themselves. Medically approved procedures for abortion, such as dilatation and curettage and menstrual regulation, were used only in 9.1% of cases. Most abortions were caused by inserting a foreign object, such as a stick, into the uterus. Abortion complications after medically approved procedures were only 4.9%. Fatal cases were more likely to occur in advanced pregnancies. It is estimated that in 1978 there were 780,000 abortions in Bangladesh, resulting in 7800 deaths.

Induced abortion in rural Bangladesh (mortality levels and physicians' attitudes).

PIP: Reports on the 1st nationwide survey on incidence of abortion related mortality in Bangladesh. Abortion is illegal except where a woman's life is in danger, but is believed to be commonly practiced for termination of unwanted pregnancies by village "dais" and other untrained practitioners. Data on all maternal deaths was collected from midwives, nurses, family welfare visitors, rural physicians, obstetricians, and other workers in some 800 health centers, covering all accessible areas of Bangladesh. Of 1933 pregnancy related deaths, 498 were found to be due to complications from induced abortions. These represented some 31% of the cases hospitalized from abortion related complications. Village dais performed 42% of the abortions reported. Nearly 1/2 were induced by inserting an object such as a stick or root into the uterus. Nearly 80% of the women were aged 20-39, with a mean of 3.1 living children. 46.3% of the abortions were conducted in the 1st trimester, 38.7% in the 2nd, and 15% in the 3rd. Fatalities occurred more frequently among those further along in gestation. On the basis of these and other findings, it is estimated that if all abortions reported had been conducted by physicians using medically approved procedures, 84% of the reported deaths could have been avoided. Using various data, an estimated 7800 women are thought to have died in Bangladesh in 1978 due to abortion complications, while an estimated 500,000 births were averted by abortions that year. In another part of the survey, 379 physicians were interviewed about their attitudes toward abortion. Nearly 99% indicated approval of abortion in 1 or more circumstances not approved by law. Other recent surveys have shown considerable approval of abortion. The government may wish to consider expanding programs for training physicians and medical practitioners to perform menstrual regulation and abortions safely.^ieng

Induced abortion in rural Bangladesh: mortality levels and physicians' attitudes.

PIP: Between December 1978-May 1979, 1118 health workers in 63 hospitals and 732 nonhospital facilities were interviewed to identify case reports of maternal and abortion-related deaths in Bangladesh. Of 1933 pregnancy-related deaths identified, 498 (25.8%) were due to induced abortion. Findings of an earlier study of maternal mortality was used to estimate that about 21,600 pregnancy-related deaths occur each year in Bangladesh. An estimated 7.5% of all pregnancy-related deaths were identified in this survey. Health workers reported 1590 cases of complications from abortion, of which 498 (31.3%) ended in death. Village dais (traditional birth attendants) and traditional practitioners were the largest groups of operators (42.1% and 18.1% respectively). Menstrual regulation or dilatation and curettage (medically approved procedures) were used in only 9.1% of the cases. Nearly 1/2 of the complicated abortions were induced by inserting a foreign object, such as a stick or root (sometimes treated with an herb), into the uterus and leaving it until either abortion or complications occurred. The proportion of complicated abortions resulting in death was lowest for medically approved procedures (4.9%) and highest for vigorous physical activity (100%) and abdominal pressure (66.7%), although the last 2 accounted for only 2.3% of abortion procedures. Women who died after abortion had a longer duration of pregnancy than women who survived. An extrapolation from these results gives a figure of 780,000 abortions in Bangladesh in 1978 and 7800 deaths that year from abortion complications. In this study, the attitudes toward abortion on the part of 396 physicians working in rural health complexes and subdivision and district hospitals were surveyed. Most of those interviewed (98.9%), indicated their approval of induced abortion in 1 or more circumstances not approved by the abortion law of the country.^ieng

Dizziness associated with discontinuation of oral contraceptives in Bangladesh.

Data from four studies in Bangladesh indicate that dizziness is a frequent complaint of women taking oral contraceptives and the most commonly cited reason for discontinuation. Results of a fifth study showed that multiple vitamin or glucose capsules were effective in treating dizziness in about half of the women studied. Although the cause of dizziness is not clear, it may be partly due to the small stature and poor nutritional status of many Bangladeshi women.

PIP: Data from 5 studies recently conducted in Bangladesh regarding dizziness as a major side effect of oral contraceptive (OC) use were reviewed. The Bangladeshi women describe dizziness as "Mata gurai" (headspinning), a sensation of rotary motion unaccompanied by nausea or vomiting. It appears to mimic the characteristics of postural hypotension rather than true vertigo and is often associated with generalized weakness. Both dizziness and weakness were cited by a large proportion of women in study A as reasons for discontinuation, and the 2 symptoms were often linked. Burning sensations, usually in the extremities, also proved to be a frequent cause of discontinuation. In study B, except for dizziness, there was no significant difference between women continuing OC use and those who had stopped use. The incidence of dizziness reported by discontinuers was significantly higher than that reported by continuing users. The case-control health survey used in study C corroborated the view that some complaints associated with OC use were equally common in nonusers, but the incidence of dizziness and eye problems was significantly higher in OC users than in both matched control groups. There were no significant associations found between dizziness and hemoglobin levels or blood pressure in study D. Of those women who took multiple vitamin capsules in study E, 57% reported a lessening of dizzinesss, compared with 69% who received glucose capsules.

Use-effectiveness of standard-dose and low-dose oral contraceptives in Dacca.

Five hundred women accepting oral contraceptives at an urban clinic were alternately prescribed standard-dose (50 microgram of estrogen) or low-dose (30 microgram of estrogen) combined pills. Life-table continuation rates at 12 months were approximately 40% for both groups, with no significant differences between or within the two groups after controlling for sociodemographic variables and nutritional status. Approximately three fifths of those who discontinued using both formulations cited medical reasons, especially dizziness. The low-dose oral contraceptive appeared to be as acceptable to these urban Bangladeshi women as the higher-dose pill.

PIP: Results of an urban comparative study of continuation rates and reasons for discontinuation of standard-dose and low-dose oral contraceptives are presented. 500 females were alternately given standard-dose (0.5 mg of DL-norgestrel with 50 ug of ethinyl estradiol) or low dose (0.15 mg of levonorgestrel with 30 ug of ethinyl estradiol) pills. Nutritional status was measured according to Huffman's method. 110 women were excluded from the analysis for various reasons, leaving 192 standard-dose and 198 low-dose acceptors. Cumulative life-table rates show a slightly higher, but statistically insignificant continuation rate for low-dose acceptors at 3, 6, 9 and 12 months (40% for both groups). When age, parity and nutritional status were controlled, no significant differences in continuation rates were observed either between or within the 2 groups. Medical reasons, especially dizziness, accounted for nearly 1/2 of standard-dose discontinuation, and for about 1/3 of low-dose discontinuation. Low-dose pills were just as acceptable as the standard dose in this urban setting.

A comparative study of standard-dose and low-dose oral contraceptives in rural Bangladesh.

Fieldworkers in a rural area of Bangladesh distributed two kinds of oral contraceptives to women accepting this method; 286 women received a standard-dose oral contraceptive and 366 women one mile away were given a low-dose pill of the same formulation. Continuation rates at 12 months were 86% for the standard-dose and 75% for the low-dose pill. Worker performance accounted for some of the difference, but the results suggest that the lower-dose pill is less acceptable in rural Bangladesh than the standard-dose pill of the same formulation.

PIP: A study was undertaken in rural Bangladesh to compare continuation rates of standard-dose Norinyl in 286 acceptors, and continuation rates of low-dose pill of the same formulation, Brevicon, in 357 acceptors. Acceptors of Norinyl were generally younger and better educated, while socioeconomic characteristics of both groups were similar. The cumulative continuation rate was significantly higher for Norinyl acceptors from 6 months on. Main reason for discontinuation was pregnancy. Continuation rates for both types of pill, however, appeared to be high; this fact suggests that either pill could be acceptable, and that differences in continuation rates were not caused by differences in age and education, but by differences in the performance of the field workers who were gathering data.

On pregnancy among pill acceptors in rural Bangladesh.

PIP: In a study comparing the use-effectiveness of 2 kinds of oral contraceptives (OCs)--1 regular dose and 1 low-dose--in a rural area of Bangladesh, pregnancy and amenorrhea or suspected pregnancy were the 2 main reasons for discontinuation. The continuation rate at 12 months was approximately 80%. This paper reports the findings of a follow-up study. The initial study was conducted in rural Manikganj. 6 female workers were used to motivate and distribute OCs among acceptors. 645 acceptors were included in the study and were followed monthly by home visits. After 12 months, 129 acceptors had discontinued, including 62 for pregnancy or amenorrhea. These 62 acceptors were visited and interviewed using a special questionnaire designed to determine as accurately as possible the reason for the pregnancy or suspected pregnancy. 9 of the 62 cases were pregnant before starting the OC. Of the remaining 53, 27 cited pregnancy and 26 gave amenorrhea as the reason for discontinuation. The validation study showed that only 14 of the reported 27 were actually pregnant, 7 of the 26 with amenorrhea. Over 1/2 of the 62 women who discontinued OCs for pregnancy or suspected pregnancy had irregular menses. Temporary discontinuation of the OC appeared to be the reason for the 21 verified pregnancies. There were no significant differences in the socioedemographic characteristics of all acceptors and the pregnant women. A simple pregnancy test and menstrual regulation services would be useful for community based programs using OCs. Visits to the homes of relatives were apparently responsible for 50% of the pregnancies. Acceptors should be encouraged to always take their OCs with them.^ieng

Importance of correct identification of intrauterine contraceptive device.

PIP: A study to ascertain the proportion of patients who could identify their IUDs was carried out in a large hospital. Interviews were conducted with 268 women using 4 different types of IUDs. However, only 44% of women wearing the Dalkon Shield gave the correct response; this finding is disturbing because of the evidence of association of the Dalkon Shield with fatal second-trimester abortions. It is advisable to provide every IUD user with a card showing IUD type, date of insertion, and when reinsertion is necessary, which is especially important with the medicated IUDs, which must be periodically removed and replaced.^ieng

Comparison of continuation rates of intrauterine devices.

The validation of reports of the performance of intrauterine contraceptive devices (IUDs) is fraught with confounding factors such as different protocols, populations, and clinic environments. Two-year life table continuation rates from a comparative study of the Lippes loop, TCu-200, and Dalkon shield are reported from a single clinic in which 1626 insertions were performed by two obstetrician/gynecologists. The difference between the highest and lowest parity-standardized continuation rates for the three devices was only 3.7 percentage points after 2 years of use. The TCu-200 and Dalkon shield yielded significantly lower expulson rates than the Lippes loop. The more recently developed IUDs do not appear to have higher continuation rates than the Lippes loop.