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Maternal Mortality the Millennium Development Goals

(MDGs).
By: Timothy Oliveira, Henry Jiang, Alanna
Fitzgerald-Husek and Paul B. Jones (Class 2011) Mrs. Elenor Mwesigye 27 year old
woman is rushed in to the Mbarara
“An estimated Hospital in Mbarara, Uganda by her
6,000 mothers die family in the back of a truck after
in childbirth every developing a severe post partum
year [in Uganda]. hemorrhage. You have just arrived in
The cause? Lack Uganda one week ago for five weeks of
of skilled post-MF4 electives, currently you are
attendants and assigned to the OB ward, and you’ve
emergency care. been asked to assess this patient.
More often than not, if mothers do arrive
at a care facility, they're already half Postpartum hemorrhage (PPH) is defined
dead. …It takes about four hours for a as any blood loss that has the potential to
mother to bleed to death after delivery. produce hemodynamic instability.
But when you deliver at home and live Typically it is divided into two
two hours from the nearest clinic, time is categories early and late PPH. Early
not in your favour.” – Dr. Jean PPH occurs within first twenty four
Chamberlain Froese hours postpartum while late PPH occurs
twenty-four hours to twelve weeks
Maternal mortality is arguably one of the postpartum. PPH occurs in
most under reported stories of our time. approximately five percent of all
More recently though it has garnered deliveries and is the leading cause of
some much needed attention of leaders maternal mortality globally.
from the Group of 8, a group of the
world’s major advanced economies. On physical exam the patient is in
Canada, which hosts this year’s G8 distress. She is quite agitated and her
meeting in Muskoka, is supporting a skin is clammy. She is hypotensive and
plan to improve maternal and child dyspneic. You can’t seem to find a
health in the world’s most vulnerable peripheral pulse. You start calling for
regions. help. You also start searching for
gloves, which are in short supply. This
Some may ask, why focus on maternal, woman has an active vaginal bleed, and
newborn and child health? Sophia Loren you are aware that that HIV and other
once said, “When you are a mother, you infectious diseases are prevalent in
are never really alone in your thoughts. Uganda.
A mother always has to think twice,
once for herself and once for her child.” While Canada and Uganda both have
This simple yet profound statement populations of approximately 33 million
embodies a reality recognized by experts people, in many ways this marks the end
at the United Nations Development of their similarities. Uganda has a total
Programme, and is the reason why fertility rate of 6.37 children
maternal health is critical to born/woman (ranking 2nd globally)
development. It is goal number five of compared to Canada where the average
is 1.58 children born/woman (ranking after a long and complicated labour
178th). Another dramatic contrast is which lasted approximately 18 hours.
maternal mortality ratio, which is a ratio She laboured at home in a small village
representing the annual number of about one hour outside Mbarara and
deaths of women from pregnancy-related was attended to by her sister and mother
causes per 100,000 live births. In in law (neither of whom have any formal
Uganda the ratio is 550 while Canada it training as birth attendants). This was
is 7. More concretely lifetime risk of her fifth pregnancy and would have been
maternal death is 1 in 11000 in Canada her fourth child, her third pregnancy
compared to 1 in 25 in Uganda. ended in an early miscarriage. Her
previous pregnancies were spontaneous
Maternal Mortality By The vaginal deliveries with no major
Numbers complications.
 Hemorrhage 25%
 Infections 15% Recognizing your limited knowledge you
 Eclampsia 12% ask the Resident about causes of
postpartum hemorrhage. He says it’s the
 Obstructed labour 8%
four T’s: Tone, Tissue, Trauma, and
 Unsafe abortion 13% Thrombin (meaning a coagulopathy).
 Other direct causes 8% You remember what you learned in MF3
 Indirect causes 20% and do your best to manage the
The world health report 2005 – Make every mother
hemorrhage by externally massaging the
and child count. Geneva, World Health Organization, woman’s uterus as the Resident looks
2005
One of the Ugandan Residents arrives for lacerations of the cervix, vagina or
with extra gloves. You begin going perineum. You are worried as Mrs.
through the ABCs. You ask if there is Mwesigye looks increasingly unwell and
any oxygen for this woman but the continues to lose more blood.
Resident says that there is no oxygen
available for her at this time and that
the only option would be to take oxygen
from a more stable patient to give to this
woman. You begin trying to start an IV
but after repeated attempts you ask for
assistance from the Resident and ward
nurse. Two large bore IVs are placed
and you begin giving the patient normal
saline. You ask about cardiovascular McMaster Medical Students walking to Mbarara
monitoring equipment and are reminded Hospital, Uganda. Photo by Natalie Chan.
that given limited resources you will
need to rely heavily on signs from your You ask if there are any uterotonics like
clinical examination. Oxytocin or Ergonovine, but they do no
have either of these. The nurse says the
You gather her history with the hospital does have a limited supply of
assistance of an informal interpreter Misoprostol which is administered. The
and the patient’s family. You learn that patient needs an urgent blood
she just gave birth to a stillborn child transfusion and surgical intervention.
Unfortunately, before this can be population lives, more than half in sub-
arranged, Mrs. Mwesigye passes away, Saharan Africa alone.
despite the Resident’s best efforts. You
are quite upset and the Resident takes Much more needs to be done to protect
you outside to talk. mothers and their children in the
developing world. If children are the
He reminds you that maternal mortality future, then mothers serve a critical role
is an all too common problem in his in guiding and nurturing their offspring
country and that often it is not possible and indeed our collective future. As
to save mothers who present to the Sarah Josepha Hale said, “No influence
hospital so late. He encourages you to is so powerful as that of the mother”. It
take the rest of the day off to process is time we do more to save the mothers.
what you have just witnessed and you
thank him for his understanding and For more information about maternal
commend him on his heroic efforts. He mortality:
says, “Sometimes you just have to be  http://www.who.int/making_pregnancy_safe
comfortable not knowing all the r/topics/maternal_mortality/en/index.html
answers”. You are amazed by the  http://www.undp.org/mdg/goal5.shtml
knowledge and resourcefulness of the  http://www.savethemothers.org/
Uganda physicians and nurses.  http://www.intrahealth.org/page/intrahealth-
voices-life-saving-practice-can-change-
Countries say they are committed to mothers-fate
reducing the maternal mortality ratio by
seventy-five percent by 2015. Despite Authors’ note: The goal of the continuing
this commitment between 1990 and Global Health Committee (GHC) article
2005 the maternal mortality ratio has series in Placebo is to provide you with an
only been reduced by five percent introduction to neglected infectious diseases
globally. Experts agree that MDG Goal and raise awareness about issues relevant to
global health. While the actual cases discussed
number five lags behind all others. Sadly are fictional, we have tried our best to ensure
ninety-nine percent of all maternal that the natural history, clinical
deaths occur in the developing world, manifestations, investigations and treatments
where eighty-five percent of the are true to life.