Mothers Make the World Go Round

Hello Folks,

In this week's lecture on maternal and child health we learned from Andy that moms indeed carry the burden of the world's population through pregnancy, birth, and child care.  We wouldn't be who we are without the help of some mom somewhere during our lives.  So why is it that while the maternal mortality ratio (expressed as the proportion of women of who die from a pregnancy/birth-related complication per 100,000 live births) is declining globally, the MMR continues to remain very high in low-middle income countries when compared with developed economies, according to WHO and UNICEF?  For example, WHO reports that the MMR in Sierra Leone in 2010 was 890 deaths per 100,000 live births (down almost 31% from 1,300 in 2000) compared with the US which had 21 deaths per 100,000 live births in 2010 (up about 50% from 14 in 2000).   In 2012, the CDC reported that of the 3,952,937 births in the US, 32% were delivered by Cesarian section, 11.5% were preterm (< 37 weeks gestation), and 8% were low-birth weight (< 2,500 grams or 5 lbs).  As shown during Andy's lecture and this 2012 study of surgical activity in rural Ethiopia, many LMICs are not equipped to provide C-section services, even at the regional hospital level where this is a routine service offered in higher income countries, due to a lack of trained personnel, i.e., they report "only 76 health workers ... are providing a surgical service [including C-sections] to this sample population of 12.9 million people."   Consider we saw last week that local technicians can be successfully trained to perform trichiasis repair (when the eyelashes abnormally turn inward due to Chlamydia trachomatis infection and result in scarring of the cornea lens and blindness). 

So is the main barrier to the provision of C-sections at rural regional hospitals in sub-Saharan Africa (SSA) a function mainly of human resources? 

On the prevention side of the MCH equation, a woman's level of education is a strong predictor of severe maternal outcome, as shown in this 29 country, cross-sectional survey published two days ago in the British Journal of Obstetrics and Gynaecology, which presents data that indicate, when controlling for confounding variables, women with the least education are 5.6 times more likely to have a severe maternal outcome, including maternal death, when compared with women who have higher levels of education.


Clearly,  Millennium Development Goal (MDG) 2, which calls for universal primary education, will address this problem of MMR while also supporting MDG 5 (Target 5A), which calls for the reduction of the maternal mortality ratio by three quarters between 1990 and 2015. These are mutually reinforcing goals.

However, neither can succeed without the other.  Page 14 of the MDG 2013 Report shows that SSA has made significant progress in MDG 2, with an adjusted net enrollment rate in primary education of 77%, but still lags behind other regions.  Page 28 shows that maternal mortality has declined by nearly half since 1990, but still falls far short of a 75% reduction of maternal deaths, as called for by MDG 5A.  Access to modern contraceptives is hugely important to the economic viability of a family and reducing MMR.  Here is a listing by CDC of the effectiveness of contraceptives for the prevention of pregnancy.  Surveys of women and couples in LMICs indicate a desire to plan or space births, if modern contraceptives were available, as shown in this study in Burkina Faso.

Community Empowerment Meeting

Finally, I promised some information on female genital cutting (FGC), an ancient practice in many countries in SSA, not unlike footbinding was in China (which ended in the 20th century), both considered violent practices against women.

Here is an inspirational story posted yesterday in the Huffington Post by my longtime friend and colleague Molly Melching who has been instrumental in helping Senegal and other countries in SSA abandon the practice of FGC, through her organization Tostan (which means "breakthrough" in Wolof, the local language of Senegal).  Here is a short clip on how Tostan approaches the problem of FGC through education.  And this is longer clip by Tostan which shows how changing attitudes and behavior towards a traditional practice like FGC is indeed possible, if probably approached.  I think you'll find the cinematography and content of both these clips beautifully done.   

Qs for thought:  What is the Tostan approach?  Can it be replicated in other cultures?  What should be the post-2015 MDGs?  With wireless access greatly expanding in SSA, could nurses, at a regional hospital without a surgeon or trained physician, be "virtually supervised" to perform a C-section, assuming they have received requisite basic training and have the necessary equipment (recall the 76 number per 12.9 million people noted above)?

See you next week,

Jim