Unsafe abortion in adolescents.

Every year, an estimated 2.0-4.4 million adolescents resort to abortion. In comparison with adults, adolescents are more likely to delay the abortion, resort to unskilled persons to perform it, use dangerous methods and present late when complications arise. Adolescents are also more likely to experience complications. Consequently, adolescents seeking abortion or presenting with complications of abortion should be considered as a medical emergency. Issues requiring special attention in the management of abortion complications in adolescents are identified. Approaches to adolescent abortion should involve all levels of the health care system, as well as the community, and should include not only management of the consequences of unsafe abortion, but also post-abortion contraception and counseling. Prevention of unwanted pregnancy by providing information on sexuality, ensuring that reproductive health services are adolescent-friendly, creating a supportive environment, building young people's social and decision-making skills, and offering counseling in times of crisis are highlighted.

Maternal mortality at the end of a decade: signs of progress?

Maternal mortality is an important measure of women's health and indicative of the performance of health care systems. Several international conferences, most recently the Millennium Summit in 2000, have included the goal of reducing maternal mortality. However, monitoring progress towards the goal has proved to be problematic because maternal mortality is difficult to measure, especially in developing countries with weak health information and vital registration systems. This has led to interest in using alternative indicators for monitoring progress. This article examines recent trends in two indicators associated with maternal mortality: the percentage of births assisted by a skilled health care worker and rates of caesarean delivery. Globally, modest improvements in coverage of skilled care at delivery have occurred, with an average annual increase of 1.7% over the period 1989-99. Progress has been greatest in Asia, the Middle East and North Africa, with annual increases of over 2%. In sub-Saharan Africa, on the other hand, coverage has stagnated. In general, caesarean delivery rates were stable over the 1990s. Countries where rates of caesarean deliveries were the lowest--and where the needs were greatest--showed the least change. This analysis leads us to conclude that whereas there may be grounds for optimism regarding trends in maternal mortality in parts of North Africa, Latin America, Asia, and the Middle East, the situation in sub-Saharan Africa remains disquieting.

Assessing the burden of sexual and reproductive ill-health: questions regarding the use of disability-adjusted life years.

The use of the disability-adjusted life year (DALY) as the unit in which to calculate the burden of disease associated with reproductive ill-health has given rise to considerable debate. Criticisms include the failure to address the problem of missing and inadequate epidemiological data, inability to deal adequately with co-morbidities, and lack of transparency in the process of ascribing disability weights to sexual and reproductive health conditions. Many of these criticisms could be addressed within the current DALY framework and a number of suggestions to do so are made. These suggestions include: (1) developing an international research strategy to determine the incidence and prevalence of reproductive ill-health and diseases, including the risk of long-term complications; (2) undertaking a research strategy using case studies, population-based surveillance data and longitudinal studies to identify, evaluate and utilize more of the existing national data sources on sexual and reproductive health; (3) comprehensively mapping the natural history of sexual and reproductive health conditions--in males and in females--and their sequelae, whether physical or psychological; (4) developing valuation instruments that are adaptable for both chronic and acute health states, that reflect a range of severity for each health state and can be modified to reflect prognosis; (5) undertaking a full review of the DALY methodology to determine what changes may be made to reduce sources of methodological and gender bias. Despite the many criticisms of the DALY as a measurement unit, it represents a major conceptual advance since it permits the combination of life expectancy and levels of dysfunction into a single measure. Measuring reproductive ill-health by counting deaths alone is inadequate for a proper understanding of the dimensions of the problem because of the young age of many of the deaths associated with reproductive ill-health and the large component of years lived with disability from many of the associated conditions.

Some thoughts on ICPD+5.

PIP: This article concerns the International Conference on Population and Development (ICPD) held in Cairo in 1994. The 1960s were the years when the UNFPA was conceived and established with a mandate to raise awareness about the population problem and to assist developing countries in addressing these problems. At that time, the topics of discussion were focused on population bombs, demographic entrapment, scarcity of food, water, and renewable resources. The concern on population dates back much further of course to Malthus and his contemporaries and their analysis of the relationship between population growth and food availability. Many population programs and policies were implemented to address the population problems in developing countries such as the rapid increase in availability of technologies for reducing fertility. In contrast, the present Cairo agenda paid more attention to women's empowerment, autonomy and the improvement of their political, social, economic and health status for the attainment of sustainable development. The trend towards the feminist agenda explains the continuing tensions, so vociferously expressed during the ICPD+5 process, between conservatives and progressive groups.^ieng

Lessons on safe motherhood.

An outline is given of progress made in understanding the causes of maternal mortality since the Safe Motherhood Initiative was launched a decade ago. It remains vital to analyse why women are dying from pregnancy-related conditions and to identify the weak links in the chain of care.

PIP: The first global estimates of maternal mortality were made by the World Health Organization (WHO) in 1987. Until then, the world was largely ignorant of the risks associated with pregnancy and childbirth in developing countries. The discovery that approximately 500,000 women died each year following pregnancy-related complications led to the development and implementation of the Safe Motherhood Initiative, a multi-agency effort to formulate strategies against the problem in a range of settings. WHO, a cosponsor of the initiative, has continued to monitor the situation while collecting data on the effectiveness of measures taken. However, while much has been learned about maternal mortality, there is little global evidence of progress in the field. Recent WHO and UNICEF estimates have even shown that the problem of maternal mortality is worse than was originally thought, with the coverage of maternal health care services inadequate in most developing countries. There is no indication that the level of maternal mortality has declined and little indication that the necessary interventions are reaching more women now than they did 10 years ago. Aspects of the initiative do, however, give reason to be cautiously optimistic, especially the recent consensus over how proven interventions can be implemented in extremely resource-limited settings. The chain of care, balancing interventions, avoiding overmedicalization, matching technology with setting, and basing interventions upon the available evidence are discussed.

Improving access to quality maternal health services.

PIP: The accessibility of maternal health care services depends on more than their mere existence. While access to routine prenatal care can be increased through use of mobile outreach clinics or peripheral health facilities, access to care for delivery is complicated by the unscheduled nature of labor, by women's other responsibilities, and by fears for women's safety during night travel. Current modes of service delivery must be changed to make care accessible. Physical barriers posed by lack of communication and transportation must be overcome. Possible strategies include establishment of maternity waiting homes, emergency transport and referral mechanisms, and enhanced communications systems. Another strategy is to authorize health care workers at the lowest level of the health care system to perform emergency obstetric services, such as Cesarean sections. Cost is also a barrier, and institution of user fees has prevented many women from seeking care. There are even hidden costs when services are provided free or for a nominal charge. Efforts to overcome these economic barriers include health insurance schemes. In the long term, communities must be educated to recognize and respond to obstetric emergencies, and the quality of health care offered to women must be improved. In addition, communication must be improved between formal and informal health care systems, between communities and health care facilities, and between women and providers.^ieng

Maternal mortality -- how big a problem do I have and how can I measure it?

PIP: The original sisterhood method asks respondents how many of their sisters reached adulthood, how many have died, and whether those who died were pregnant near death. For technical reasons, the approach should not be used where the total fertility rate is under 3, where fertility has declined steeply, or where there has been major migration. The method is relatively simple and inexpensive to use. However, one major disadvantage is that the estimate relates to a period 10-12 years before the survey, limiting its use for monitoring recent trends. The direct method is a variation from the original approach and is used in the Demographic and Health Surveys. In the direct method, respondents are asked more detailed information on their sisters, a lengthier, more complex process. The sisterhood method has been adapted to measure maternal mortality. The author discusses when it is appropriate to use the method, preparation of a sisterhood study, using the results, learning about why women are dying, and why an estimate of the magnitude of a given maternal mortality problem will suffice.^ieng

Quality health care for women: a global challenge.

This paper discusses barriers to the provision of high quality care from the perspectives of the health system and female clients, and interventions that have been developed to overcome these barriers. These interventions are in the area of reproductive health, where most attention to women's health has focused; they consist mainly of assessment tools that can be used by peripheral health workers and rural women themselves. The paper argues that in nonreproductive health generally, there is a dearth of information on the biological and social determinants and consequences of infection and disease from a gender perspective. Recommendations are made for further research on quality of care and for practical interventions with application to women's health, both within and outside the reproductive context.

PIP: This paper considers problems of definition, measurement, and management of quality health care for women as well as barriers to quality of care, including information, access, and use barriers. It then describes a number of interventions supported by the World Health Organization designed to improve the quality of care provided and women's access to and use of health services. Interventions need to take into account the perspectives of both health workers and women, as well as the constraints they face in providing and receiving services, respectively. The authors broadly focus upon women's health, considering reproduction as well as other health concerns such as tropical diseases endemic to developing countries. They argue that in nonreproductive health, there is a general lack of information upon the biological and social determinants and consequences of infection and disease from a gender perspective. Recommendations are made for further research into the quality of care and for practical interventions with application to women's health, both within and outside of the reproductive context.

Maternal mortality.

A new approach to measuring maternal mortality indicates that there are some 585,000 maternal deaths, 99% of them in developing countries. This is around 80,000 deaths more than earlier estimates have suggested and indicates a substantial underestimation of maternal mortality in the past. There is a greater disparity in levels of maternal mortality between industrialized and developing countries than in any other public health indicator. While significant progress has been made in reducing infant mortality, the same is not true for maternal mortality. Although the actions needed to reduce maternal mortality have long been known, 1 woman in 50 is still dying as a result of pregnancy-related complications and the figure rises to 1 in 10 in many parts of Africa. By contrast, the figure for developed countries can be as low as 1 in 8,000.

The epidemiology of unsafe abortion.

PIP: Data on unsafe abortions, defined as those provided by persons lacking the necessary skills in an environment failing to meet medical standards, are scarce given the legal and ethical implications of reporting such procedures. However, the World Health Organization estimates that 20 million unsafe abortions occur each year, 90% of them in developing countries under conditions of illegality. The rate is 8/1000 women of reproductive age in more developed countries compared with 17/1000 in less developed countries; the highest rate (47/1000) exists in Latin America. Worldwide, there are an estimated 70,000 unsafe abortion-related deaths each year; again, the risk of mortality is at least 15 times higher in developing than developed countries. In addition, about 20-30% of unsafe abortions result in reproductive tract infections, many of which produce infertility. Of concern is the increase in unsafe abortion among unmarried adolescents who lack access to fertility control services. Urged is a reframing of the abortion issue on the basis of a commitment to women's reproductive health and well-being.^ieng

Excessive hazards of pregnancy and child birth in the third world.

PIP: The National Conference on Safe Motherhood in 1987 established the goal of reducing maternal mortality by 50% by the year 2000. At that time, there were 500,000 deaths from maternal causes, of which all but about 4000 occurred in developing countries. 87% of births globally occurred in developing countries. Maternal mortality was highest in Africa, particularly in Western, Central, and Eastern Africa. The average risk of dying from pregnancy related causes in Africa was over 1 in 20 compared to the 1 in 2000 risk in developed countries. In southern Asia there were 29% of the world's births, but about 50% of the world's maternal deaths. African maternal mortality could reach 1000/100,000 live births in rural areas and 500/100,000 in some cities, while in rural Bangladesh the figures were 600/100,000 and in rural Andhra Pradesh, India, 874/100,000 in 1984-85. The ratios in remote rural areas of China were 200/100,000; the ratios could be as high as 700/100,000 in some areas of Southeastern and Western Asia. In Latin America, the average was 200/100,000 without consideration of underreporting which was estimated at the highest at 60%. In the developed countries of Europe, maternal mortality averaged 10/100,000 or lower; a high value could be 30/100,000. Because fertility was low in developed countries, the actual numbers were 4000-5000 or 1% of the total. Global risks declined by about 5%, but births have increased by 7%. In developed countries, the maternal mortality ratio declined by 13%. Some evidence of decline was apparent in Asia, except for East Asia, and in Latin America. Little progress has been made in improving maternal mortality when the African lifetime risk of dying from pregnancy-related causes was 1 in 20 and a woman's risk in a developed country was 1 in 2000.^ieng

Maternity care for all.

PIP: Until the 20th century, women and families worldwide knew that it was always a possibility that women would die from childbearing (e.g., over 2000 maternal deaths/100,000 births in Europe). Increased knowledge about pregnancy and its complications and the application of that knowledge in maternal health care systems in developed countries reduced maternal mortality considerably (e.g., 20 in northern Europe). Improvements in delivery management helped greatly to reduce maternal deaths, which include aseptic techniques, appropriate use of forceps, safe blood transfusion, sulphonamides, and proper management of preeclampsia and eclampsia. Maternal mortality is still high in developing countries (e.g., 5% of women in some parts of Africa die from a pregnancy-related condition) where 99% of all maternal deaths occur. These pillars of family life die in the prime of their life and often leave other children. Their loss adversely affects social and economic development. Just 78 countries (35% of the world's population) have a vital registration system recording causes of death, thereby making it difficult to understand the extent of maternal mortality. The 1st cause of maternal death to fall in developed countries and now in developing countries is sepsis. Other causes of maternal death are obstetric hemorrhage, eclampsia, ectopic pregnancy, unsafe abortions, and obstructed labor. Lack of access to maternal health services keeps many women with pregnancy complications from receiving the care they need to survive. Trained persons help only about 50% of women worldwide with labor and delivery. Upgrading of local health centers and training midwives in recognizing complications and in aseptic delivery techniques are needed to improve the quality of maternal health care. Each health center must have the means to transport women to district hospitals. Health centers must offer contraception to prevent unwanted pregnancies. Countries need to reduce the social inequalities that women face.^ieng

Measuring maternal mortality.

PIP: There are various methods of measuring maternal mortality each with its own advantages and disadvantages. Most official maternal mortality statistics underestimate true maternal mortality levels. Major reasons for underestimates depend on death certification practices and the advancement of the vital registration system. Only 35% of the world's population routinely record cause of death. Misclassification of the cause of death accounts for much of the bias in areas with good vital registration. In France, clerks miscode maternal-related causes of death as something else, e.g., they misclassified cerebral hemorrhages as diseases of the circulatory system and not complications of pregnancy, childbirth, and the puerperium. In countries with few maternal deaths, pregnant or puerperium women in life-threatening conditions are transferred from obstetric departments so cause of death on the certificate may not be the obstetric condition which precipitated the fatal series of events. Governments must determine the type of measurement method for maternal mortality by balancing precision against human and financial costs. Statisticians can measure the maternal mortality rate using several methods. They can include questions about maternal mortality such as maternal deaths of sisters of the adult women or of any women they know who had died from maternal causes in the last year in ongoing household surveys. These surveys tend to be expensive, however . A more cost-effective and successful method is reproductive age mortality surveys which consist of investigating the causes of all deaths of women of reproductive age. If civil registration or other population-based data do not exist, researchers can use hospital data despite their limitations. They can also use records at the primary care level. They can use incomplete data to estimate maternal mortality and to evaluate rates obtained from civil registers, studies, or other sources.^ieng